Sample Letter For Medical Evidence Of Domestic Violence


Response from health professional to request for
evidence of injuries/condition consistent with domestic
This example letter has been designed by the Ministry of Justice to be used by
doctors (including GPs), nurses, midwives, practitioner psychologists & health visitors
(or, in the examining health professional’s absence, another health professional who
has access to the applicant’s medical records), when responding to requests for
evidence of injuries or condition consistent with domestic violence.
Information required is highlighted and instructions are italicised. Please delete any
unnecessary text and instructions (including this introduction) before sending.
HEADED LETTER [Please can you ensure that the letter is on headed paper from
the surgery or hospital where the doctor, nurse, practitioner psychologist, health
visitor or midwife practises.]
[Addressee name]
[Your Address]
[Your E-mail (if applicable)]
[Your Contact telephone number]
[GMC/NMC/HCPC] Registration Number:
[GMC/NMC/HCPC] Registration Number]
Dear [Insert name of addressee],
Name of applicant: [Name of applicant]
I understand that [APPLICANT’S NAME] (‘the Applicant’) wishes to access legal aid
for a family dispute as a victim of domestic violence. For this reason I have been
asked to provide a letter in accordance with regulation 33 of the Civil Legal Aid
(Procedure) Regulations 2012.
Accordingly I can confirm that the Applicant presented [himself/herself] to me [insert
relevant health professional’s name] on the [DATE WHEN CONSULTATION
OCCURRED] (being within 5 years prior to the Applicant’s intended application for
legal aid). After examining them I [insert relevant health professional’s name] was
satisfied that the [injuries [and/or] condition] that the Applicant presented me [insert
relevant health professional’s name] were consistent with domestic violence.
I understand that the Ministry of Justice and the Legal Aid Agency recognise that the
great majority of physical injuries and many non-physical conditions could be caused
by domestic violence.
I understand that this evidence is only required for a decision on whether or not to
grant legal aid – it is not designed to prove domestic violence in the context of a
criminal or civil court case.


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