Therapist Notes Subpoena Response Form
Recipient Information
Recipient Name
Organization
Address
Email
Phone
Client Information
Client Name
Date of Birth
Therapist Information
Therapist Name
License Number
Practice Name
Subpoena Details
Date Received
Court/Case Number
Request Details
Response
Information Disclosed
Information Withheld (if any) and Reason
Remarks
Therapist Signature
Date