Court Letter (Therapy Summary)

(If no valid patient authorization or court order is on file authorizing disclosure for this purpose, do not generate the therapy summary. Instead, use the alternate "Acknowledgment of Request – Authorization Required" template at the end of this document and do not include any protected health information.)

[Clinician Full Name], [Degrees/Credentials]
[License Type], [License Number], [Licensing State]
[Practice Name]
[Practice Street Address]
[City, State ZIP]
Phone: [Practice phone number]
Secure contact: [Secure email / patient portal / secure fax]

[Date in written format (e.g., January 14, 2026)]

[Recipient Name/Title], [Court or Law Office]
[Recipient Street Address]
[City, State ZIP]
[Delivery method notation (e.g., Via secure email / Certified Mail / Hand-delivered)] (Only include if relevant)

Re: [Patient full legal name], DOB: [DOB], [Case number] (Include case number only if provided; do not include SSN)

Purpose and Scope

[Purpose of letter] (State that this is a therapy summary prepared in response to a [court / legal / attorney] request; identify who made the request.) [Authority for disclosure] (Identify the legal authority permitting disclosure, including the date of the patient's signed authorization or the date and issuing authority of a court order.) [Timeframe covered] (Specify the period of treatment summarized using concrete dates; if uncertain, state the limitation.) This letter constitutes a treatment summary derived from clinical care; it is not a forensic or independent evaluation. No opinions are offered regarding custody, parenting capacity, credibility, causation of alleged events, or other psycho-legal questions.

Treatment Overview

[Treatment relationship] (Identify your role as treating therapist, modality [individual / couples / family / group], and setting [outpatient / telehealth / in-person]; include date of first session and date of most recent session. If exact dates are unknown, note that records are incomplete or dates are approximate.) [Session frequency] (Describe typical session frequency and duration during the covered period.)

Attendance: [Total scheduled], [Attended], [No-shows], [Late cancellations] (Include counts only if tracked.) [Attendance pattern characterization, e.g., generally consistent / variable due to scheduling conflicts / sporadic]

(If applicable, note any collateral contacts, care gaps, or record limitations, e.g., "I do not have records prior to [date]" or "Care transitioned to another provider on [date].")

Clinical Summary

[Presenting concerns] (Summarize reasons for seeking therapy and primary concerns in neutral clinical terms. Explicitly attribute patient-reported information using phrases such as "The patient reported..." or "Per patient report..." Avoid graphic details or adjudicating disputed events.)

Treatment goals: [Goal 1]; [Goal 2]; [Goal 3]; [Goal 4] (List 2–4 brief, behaviorally stated goals.)

Therapeutic approaches: [Approaches used, e.g., CBT-based skills, supportive therapy, motivational interviewing, trauma-informed strategies, psychoeducation] (List only approaches actually used.)

[Course and progress] (Describe baseline presentation at start of treatment, engagement, skills introduced and practiced, response over time, and functional changes such as mood regulation, sleep, work/school functioning, relationships, or coping. Conclude with current status as of the most recent session.)

Standardized measures: [Measure name(s), baseline score(s), most recent score(s), direction of change] (If not used, state: "Standardized symptom measures were not administered.")

(Include diagnosis only if explicitly requested and authorized, or if essential to explain treatment course:)
Diagnosis: [Diagnostic impression(s) with date established] (If no formal diagnosis was assigned, state: "No formal diagnosis was assigned during the covered period.")

(Include risk and safety information only if specifically requested or clinically necessary for the legal purpose:)
Risk assessment: [Date(s) of assessment, assessed level of risk, safety planning conducted, consultations, and actions taken] (Provide factual, time-bounded information; do not speculate beyond documented findings.)

Limitations

• This summary is based solely on clinical work conducted within a therapeutic treatment context; it is not a forensic or independent evaluation.
• Therapy is designed to support treatment and relies substantially on patient self-report; adversarial hypothesis testing was not performed.
• No forensic interview protocols, custody evaluation methodologies, or psychological testing were conducted. (If any were conducted, remove this statement and document in Clinical Summary.)
• No opinions are offered regarding custody, parenting time, parental capacity, credibility of allegations, causation of alleged events, or any ultimate legal issues.
• This document is a summary and does not constitute the full clinical record.

Closing

[Clinical recommendations] (Include treatment-related recommendations only, such as continuation of therapy, frequency adjustments, consideration of psychiatric evaluation, or referral to other services. Do not make recommendations about custody, visitation, sanctions, or legal outcomes. If no recommendations are warranted, omit this paragraph.)

I am available to clarify the contents of this summary within appropriate limits of authorization and professional boundaries. [Contact instructions] (Note that additional services may require a separate authorization or court order.)

Sincerely,

[Clinician Full Name], [Degrees/Credentials]
[License Type], [License Number], [Licensing State]
[Practice Name]
[Practice phone] | [Secure contact method]

Attachments: [Attendance log / Copy of signed authorization or court order / Other] (List only if included; omit line if no attachments)

(Alternate Template – Use Only If No Authorization)

(Use this version instead of the therapy summary if disclosure authority is unclear or not established. Do not include patient identifiers beyond what is minimally necessary to locate the record.)

[Clinician Full Name], [Degrees/Credentials]
[License Type], [License Number], [Licensing State]
[Practice Name]
[Practice Street Address]
[City, State ZIP]
Phone: [Practice phone number]
Secure contact: [Secure email / patient portal / secure fax]

[Date in written format]

[Recipient Name/Title], [Court or Law Office]
[Recipient Street Address]
[City, State ZIP]
[Delivery method notation] (If relevant)

Re: [Patient name or file locator] (Do not include DOB, case number, or any PHI beyond what is necessary to identify the request)

I acknowledge receipt of your request for clinical records or summary. At this time, I am unable to release protected health information without a valid, written authorization from the patient or authorized representative that specifies the information to be disclosed and the timeframe, or a court order directing release. Please provide a compliant authorization or court order, and I will respond within applicable timelines. For questions about the process, contact me via [secure contact method].

Sincerely,

[Clinician Full Name], [Degrees/Credentials]
[License Type], [License Number], [Licensing State]
[Practice Name]