CAPACITY LETTER

[Practice name]
[Address]
[Phone and email]

Date: [Date you write the letter]

To: [Lawyer's name, firm, and address]
Your reference: [File number]

Re: [Patient's full name]
Date of birth: [Date]

WHAT YOU ASKED
You asked for my opinion on whether [patient name] had the capacity to make [a will, or a power of attorney for property, or a power of attorney for personal care], to be signed on [signing date, or signed on date]. Your letter of [date] set out the legal test you rely on, and I assessed against it.

[Patient name] agreed to this assessment and to my sharing this letter, and the health information in it, with you.

MY ROLE
I am [patient name]'s [family physician, geriatrician, psychiatrist, psychologist, or other role], and have [treated or known] [him, her, or them] since [year]. I write as [the treating clinician, or an assessor you retained]. My experience in assessing cognition: [One line]

THE ASSESSMENT
Date and place: [Date, and in person at the clinic or elsewhere], [number] days [before or after] the signing
Length: [Minutes]
Present: [Who came, who was in the room, and how long I saw the patient alone]
Methods: [Interview on the decision, cognitive testing, records reviewed]
Collateral history: [From whom, with the patient's agreement, or none]

HEALTH BACKGROUND
Conditions that may affect thinking: [Conditions, or none]
Medications that may affect thinking: [Medications and doses, or none]
On the day: [No sign of delirium or acute illness, or what I saw]
Cognitive testing: [Test, score, and date. A score describes cognition; it does not answer the legal test]

FINDINGS ON EACH PART OF THE TEST
[Part 1 of the test]: [What I asked, and the answer in the patient's words]
[Part 2 of the test]: [What I asked, and the answer in the patient's words]
[Part 3 of the test]: [What I asked, and the answer in the patient's words]
Consistency: [Whether the answers held when I asked again later in the visit]
Possible influence: [Who arranged the visit, whether the patient answered for themselves, and whether their reasons seemed their own]

MY OPINION
In my opinion, on [date of assessment], [patient name] [understood, or did not understand] the matters above for [the document]. [Your reasons, in one or two sentences]

This opinion is limited to [the document] on or about [date]. Whether it meets the legal test is for you and, if the document is challenged, a court to decide.

NOT ASSESSED
[What this letter does not cover, e.g. other decisions, other dates, the contents or fairness of the document, or whether undue influence occurred]

[Your name, credentials]
[License or registration number]
[Signature]