Response from health professional to request for

evidence of injuries/condition consistent with domestic

violence
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
re"uests for evidence of in#uries or condition consistent with domestic violence$
%nformation re"uired 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 aer fro!
the surgery or hosital "here the doctor# nurse# ractitioner sychologist# health
$isitor or !id"ife ractises.%
[Addressee name]
[Address]
[Your Address]
[Your E-mail (if applicable]
[Your !ontact telephone number]
["#!/$#!/%!&!] Re'istration $umber(
["#!/$#!/%!&!] Re'istration $umber]
)ear [*nsert name of addressee]+
$ame of applicant( [$ame of applicant]
* understand that [A&&,*!A$-./ $A#E] (0the Applicant. wishes to access le'al aid
for a famil1 dispute as a victim of domestic violence2 3or this reason * have been
as4ed to provide a letter in accordance with re'ulation 55 of the !ivil ,e'al Aid
(&rocedure Re'ulations 67862
Accordin'l1 * can confirm that the Applicant presented [himself/herself] to me [insert
relevant health professional.s name] on the [)A-E 9%E$ !:$/;,-A-*:$
:!!;RRE)] (bein' within 6< months prior to the Applicant.s intended application for
le'al aid2 After e=aminin' them * [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 violence2
* understand that the #inistr1 of >ustice and the ,e'al Aid A'enc1 reco'nise that the
'reat majorit1 of ph1sical injuries and man1 non-ph1sical conditions could be caused
b1 domestic violence2
* understand that this evidence is onl1 required for a decision on whether or not to
'rant le'al aid ? it is not desi'ned to prove domestic violence in the conte=t of a
criminal or civil court case2
,A2)@2#ed2ERA7<85
The applicant has confirmed that the [injuries/condition] that [he/she]
presented to me [insert relevant health professionals name] with on [date of
consultation] were caused by domestic violence.
Yours sincerel1+
[/i'n]
[$ame of #edical si'nator1]
[-itle of si'nator1]
[&lease indicate if si'nin' on behalf of health professional collea'ue in their absence]
,A2)@2#ed2ERA7<85