Therapy Attendance Verification Letter

Practice/Clinic Name: [Practice or Clinic Name]

Address: [Street, City, State ZIP]

Phone: [Clinic phone number]

Provider Name and Credentials: [Provider name, degree(s), credentials]

License Number: [License number and issuing state/board]

Date: [Date of letter]

Recipient:
[Name/Department, Organization, Mailing Address] (Use "To Whom It May Concern" if patient will hand-deliver or recipient is unknown)

Re: [Patient full legal name], DOB: [Date of birth]

Dear [Recipient name / To Whom It May Concern]:

Authority to Disclose

[This information is disclosed with the patient's written authorization dated [authorization date] / This letter is provided directly to the patient at their request / This letter is sent at the patient's written request to [recipient name/organization]]. (Select one. If requester is a parent, guardian, or personal representative for a minor or incapacitated patient, note their legal authority.)

Purpose

The purpose of this letter is to verify attendance and dates of service only.

Attendance Verification

(Include only what was specifically requested and can be verified from scheduling/billing records. Do not include clinical content, diagnoses, symptoms, or session discussions.)

• Period of care: [First date of service] to [Most recent date of service]
• Services: [outpatient psychotherapy / behavioral health counseling / other neutral descriptor] (Include only if patient requested; omit diagnosis or codes)
• Specific dates attended: [List dates if requested] (Format dates clearly, e.g., January 5, 2026)
• General frequency: [typically seen weekly / biweekly / monthly / variable] (Include only if accurate and requested)
• Total sessions in requested period: [Number] (Include only if requested)
• Cancellations/no-shows: [Number] (Include only if explicitly requested by patient; do not include reasons)

Scope Limitation: This letter verifies attendance only and is not a clinical summary. It does not address ability to work or attend school, disability status, or need for accommodations.

Signature

The above information is true and correct to the best of my knowledge and based on clinic records.

[Provider signature]

[Provider printed name, credentials, license]

[Practice/Clinic Name]

[Contact phone for verification]