The forms presented here are to be used in conjunction with the process described in the accompanying article. If you have not read the article, please do so now.

The samples on the following pages are designed for you to copy and paste into your word processor where you can make modifications that meet your specific needs.  Feel free to copy the following materials onto a clearly labeled document.  Begin by choosing File/Save As from your browser’s menu, and save the file as a Microsoft Word Document. Then, open the document using Microsoft Word, and begin editing. Fields which need your attention are identified by “angle brackets” (<>). Fields which are in italics provide instructions to you. Underlined fields identify  information which you must provide.  To fill in your information, highlight the entire field, i.e. <name/address/telephone>, then type in your information.

When you have finished copying this information, name and save your document. Close this window to return to the article.

FORMS and SAMPLE LETTER

EMERGENCY RESPONSE TEAM PREPARATION PACKAGE

Memo to ERT

You may want to write a sample outgoing answering machine message for the Bridge Therapist. Example: “You have reached the office of <Therapist's Name>.  You may or may not have heard that your therapist is ill. My name is <Covering therapist>, <Therapist's Name> has asked me to handle her professional affairs in her absence. If you would like to speak with me in person or would like further information or help, please call me at <Phone number>.  Thank you.”

Sample Letters to Executor and Attorney:

Date <Today’s Date>

Dear Executor and or Attorney,

    Thank you for helping with these matters. Enclosed please find a copy of my Guidelines for the Disposition of my Practice. In addition you will find a copy of my malpractice insurance information.  If it is necessary to protect my estate in the event of legal action arising after my death, please contact each insurance company with whom I have a policy to arrange for additional coverage.  Please be sure to bill my estate for your time and any other expenses that you incur in executing these instructions.

With many thanks,

____________________________               <signature>

Sample Memos and Letters to your ERT: 

     Include two letters in draft form that can be mailed to clients if you are incapacitated or have died unexpectedly. It is best to prepare these letters while you are in good health, rather than waiting for an emergency. Take a few minutes to write some notes about the amount and type of information you  routinely disclose to your clients.  This will help them in deciding what to tell clients when they call to cancel your appointments.  For example, if you routinely tell all your clients where you are going on vacation and have family photographs in your office, you may want your ERT to give more detailed information about the reasons for your absence than if you have a more analytic approach to self- disclosure.

The following forms are intended to be used as samples. Please make modifications that take into account your personal and professional situation as well as the relevant state laws and regulations.

     In The Event Of My Unexpected Absence From Clinical Practice:

Date <Today’s Date>

Dear Client,
If you receive this letter, it is because I have become temporarily incapacitated and am unable to call you myself.    <Covering therapist>  , has mailed this letter, using my stationery, in accordance with an agreement we made in   <Month, year>   .  If you are currently in therapy with me, regretfully, this letter is to let you know that I am unable at present, <either to continue my psychotherapy practice or keep any further appointments.>   <Covering  therapist>   , will be handling my clinical practice. Please call her for an appointment or for information regarding an appropriate referral.  I encourage you to speak with her about the emotions that this news stirs in you and that you take the time with either her or another therapist to deal with these feelings.
As you probably know, I feel strongly about the importance of allowing adequate time and discussion for clients’ feelings about termination and other disruptions of treatment. If it is at all possible, I will make arrangements so that you can do that work with me directly. However, if, due to circumstances beyond my control, this is not possible, I hope that you will allow another therapist to assist you in that process.
<Include this paragraph in letters to be sent to former clients.> If you are not currently in therapy with me this letter is to let you know that, at least for now, I am not available for consultation.  Depending on the extent and duration of my incapacitation, I may not be available in the future. As I mentioned above,    <Covering therapist>    is handling my practice. She can fill you in, and if you need to be seen before I return to work, help you find an appropriate therapist.
I have every confidence that    <Covering therapist>    will handle this transition period ethically, competently, and discreetly for us all.  Please feel free to contact her should you have any questions.  She can be reached at <Phone number>. 

Very truly yours, 

      <Therapist’s name>     

	Termination Letter To Be Sent In The Event Of My Unexpected Death

Date <Today’s Date>

Dear Client,
      In  <Year> , a group of trusted colleagues and I agreed to create a system to provide emergency coverage for each other’s practices in the event of illness or death. Part of that agreement was to notify clients of both temporary and permanent absences if we were unable to do so ourselves. If you are receiving this letter it is because an unexpected illness or accident made me unable to complete the termination process with you in person.  I deeply regret the added difficulty caused by our not being able to say goodbye in person. This letter is part of a plan we made for handling my practice in case of emergency.
If we had had the opportunity to say goodbye in person, I would have encouraged you to ask questions of me and try to resolve any unfinished business. I would have also taken the opportunity to give you feedback about my view of your progress. Hopefully, we have been addressing these issues throughout our work together.  
Nevertheless, this letter has to serve as a poor substitute for my saying farewell in person.  Because it is being written in advance, and no one can predict the circumstances of my death, I can only speak in generalities. The first is that I have felt fortunate to be able to work with the motivated, hard-working clients in my practice. The second is that it has been an honor to work with each and every client who opened him or herself up and allowed me to see his or her fears, dreams, vulnerabilities and strengths.
I am saddened to think that we were not able to say our good-byes in person. Since I was unable to help you with this final phase of our working together, I hope that you will allow another therapist to assist you in that process.
       <Covering therapist>    will be handling my clinical practice. Please call her for an appointment or for information regarding an appropriate referral.  I encourage you to speak with her about the emotions that this news stirs up for you and hope that you take the time with either her or another therapist to deal with these feelings.    <Covering therapist>    can fill you in on memorial services and help you find an appropriate therapist. I have every confidence that   <Covering therapist>    will handle this transition period ethically, competently and discreetly for us all.  Please feel free to contact her should you have any questions. She can be reached at  <Phone number>.                                          
     In summary, thank you for allowing me to work with you. Losing a therapist is, under the best of circumstances, difficult. In some situations it can be traumatizing. I hope that you will allow yourself to accept the professional support that is available to you. 

With warm best wishes,	

      <Therapist’s name>     

Guidelines for the Disposition of My Psychotherapy Practice

<Therapist’s Name>	

I.  Intent. This document specifies my wishes regarding matters related to my psychotherapy practice, in the event of my death or inability to work. My intent is to provide for an orderly and ethical transition concerning the care of my clients, and an orderly disposition of matters relating to the business of my therapeutic practice. Some clients may be strongly affected by my illness, incapacity or death. The following instructions are thus intended to reduce the stress to my clients, colleagues, and family.

II.  Confidentiality. This is a private and confidential document, to be available only to people I have designated to handle specific professional responsibilities in my absence, as set forth below. I have given each such person a copy of this document. Additional copies are located in   <locations: e.g., locked office file drawer/cabinet, safety deposit box, attorney’s office>  . 

III.  My Personal Will. A separate will related to my personal life has been executed and filed, and a copy is on file with my attorney,       <name, phone number>      , The executor of my personal will is:     <name, phone number>    . 

IV.  Emergency Response Team. To handle clinical responsibilities in my absence, I hereby designate my Emergency Response Team.
	
	A.  Definition. The Emergency Response Team (ERT) is a specific group of my colleagues who have agreed to assist me, or my estate, in case of my inability to carry out my professional role and responsibilities.

	B.  Membership. The ERT may vote to replace members who have resigned. I authorize the following people as members of my ERT:
	1.  ___________<Name, address, phone number>________________
	2.  ______________________________________________________
	3.  ______________________________________________________
	4.  ______________________________________________________

	C.  Bridge Therapist. The ERT will function more smoothly if one member serves as a coordinator or “Bridge Therapist.” This is a transitional role of assisting clients with crises related to my absence. I authorize        <name>       , who has agreed verbally to accept this responsibility.  If the current Bridge Therapist is unable to serve, I ask that the ERT members elect another member who has the time, energy, and ability to take on such a role.

	D.  Stipulation. In the event of circumstances that interfere with my ability to continue in my role as therapist, I ask that my ERT colleagues consider the following requests and suggestions:
1.	In all actions taken by the ERT, I request the ERT be mindful of the need to protect confidentiality and that they avoid unnecessary disclosures regarding clients.
2.	I ask that the ERT ask my family members to respond to questions and needs only when absolutely necessary.
3.	I ask that ERT members use their clinical judgment about whether to pass information from my clients to my family or me.

V.  Power of Attorney. In the event of my incapacity or death, I authorize my attorney,        <name>     : to assist the ERT. Advice from an attorney that specializes in the legal issues of psychological practice can also be obtained from the American Association of Marriage and Family Therapy (800) 662-2638, the
American Psychological Association (800) 374-2721 or from your local professional association.

VI.  My Professional Premises and Materials
	A.  My Office
		1.  My professional office is located at       <full address>      . To gain access to my clinical records and professional financial information, I authorize my ERT to obtain office and file cabinet keys, voice mail codes, computer data, passwords and burglar alarm codes. To get these keys and codes, contact <name/address/phone: e.g., bookkeeper, spouse>    , or the office building     <manager, landlord>    .
		2.  If I am unable to cancel my appointments, I ask any ERT member to put a note either in my waiting room or on my office door saying:    _ <name>     , is unavailable to meet today. “Please check your answering machine for a message.” If the Bridge Therapist deems it advisable, please add: “If you have questions, contact <name of the Bridge Therapist> at <area code and telephone number>.”
	B.  Answering <Machine/Service>.  I ask the Bridge Therapist to retrieve messages from and record a new outgoing message on my office answering <machine/service>.
		1.  My office answering <machine/service> is <location/service provider>.
2.  Instructions <or codes> for recording a new outgoing message are in <location, e.g., In Case of Emergency file>.
		3.  I ask that the new outgoing message state: e.g., “You have reached the office of     <name>   , who is unavailable to keep his/her appointments this week. If you are a current client, you can expect a call shortly. Otherwise, if you would like your call returned, please leave a message at the tone, including your phone numbers and times when you can be reached.”
		4.  I ask the ERT to retrieve and respond promptly to messages and phone calls from my clients. Please keep notes summarizing your contact with my clients as you deem appropriate.

VII.  Notifying My Clients
	A.  I ask the ERT to promptly inform my current and recent clients by telephone of my inability to return to work or my death.
		1.  Phone numbers for all current clients are listed in the Client Contact Summary Sheet, in the “In Case of Emergency.” in <location, e.g., in the front of the date book in my briefcase>.
		2.  Phone numbers for significant former clients are listed the Client Contact Summary Sheet, in the file labeled “In Case of Emergency.” That file is in               <location>              .
		3.  I strongly prefer that any message is left on a client’s answering machine or with an answering service be limited to the request to return a phone call. An acceptable message might be “Hello, My name is ________. Your therapist,           <name>          has asked me to contact you regarding your appointments with <him/her>. Please call me at <area code and telephone number>.”
		4.  In the event of my sudden incapacity or death, I ask that the ERT tell my clients as much or as little information as needed on a case-by-case basis to help them process their feelings. Please keep in mind that over time, whatever you disclose about me may become public knowledge.
		5.  Some clients may ask questions and others may not. I ask that ERT members respond with as little or as much information as you deem appropriate.
		6.  <Optional> In the event that I have a debilitating, terminal illness, I ask that the ERT discourage my clients from contacting my family or visiting me without my participating in this decision.
	B.  I ask ERT members to cancel my pending appointments promptly and, to minimize disruption to my clients, to offer consultation or referrals to other therapists, or both. Pending appointments can be found in my confidential appointment book, which I keep with me, i.e.,     <location: in my office during work hours and in my home after work hours either on my desk, in my PDA or in my briefcase>    .
	C.  In addition, I ask the ERT to send my current and former clients a letter notifying them of my circumstances. Please refer to the letter I have drafted for clients in the event that I am unable to contact them myself. I wrote these letters to guide the ERT in writing a similar letter to my clients. It is in <location>.

VIII.  Maintenance of Records
	A.  Although state and local laws and regulations regarding record retention vary, generally records or a summary should be maintained for a minimum of 3 years, and up to 15 years before being destroyed. If a client is a minor, the record period is extended until 3 years after the age of majority. Outdated records should be destroyed, preferably shredded.  If you are uncertain about the requirements, please contact my state’s professional organization, national organization phone numbers are listed in Section V.
	B.  If the client requests in writing, records should be forwarded to their new treatment provider.

IX.  Professional Finances
	A.  Power of Attorney. The person with power of attorney to write checks and manage my professional finances is         <name/address/telephone>        . In the event of my incapacity or death, I have instructed this person to consult the ERT on all financial matters pertaining to my clients.
	B.  Collections. In the event of my death, client billing records will be handled by either a qualified professional, trained in handling confidential accounts, or an agreed-upon licensed mental health professional. I urge the ERT to respond to each situation using sound clinical judgment in dealing with amounts owed to my estate. 

X.  Memorial Service
	A.		____ I want or am willing to have a public memorial
			____ I do not want a public memorial
			____ I have no objection to a memorial being given in the event that friends, relatives or clients who are inclined to, wish to grieve together.
	B.  I have no objection to clients attending a public memorial service, but request that my family representative be consulted regarding their wishes.
	C.  Please see my notes regarding how I prefer that such an event be handled and my preference for special arrangements for my groups. These notes are in              <location>          .

XI.  Mental Incapacitation
	A.  If a chemical dependence, organic illness, or mental illness, that is outside of my awareness, interferes with my judgment to the degree that may jeopardize the well being of my clients, I ask that one or more ERT members discuss this with me directly and request that I seek consultation or treatment from an appropriate mental health professional.
	B.  If a majority of the ERT continues to be concerned about the well-being of my clients I encourage them to contact my licensing board:                       <name/address/telephone>                         .
	C.  <Optional> For additional information, I authorize the ERT to contact and exchange any necessary information with the following people:
		My consultant:           <name/telephone>           .
		My <current/former> therapist:            <name/telephone>           .

XII.  Conclusion:  I thank my Emergency Response Team members in advance for your help during this difficult time. I regret any problems these requests may cause. I hope that you also take time to take care of yourself. I have chosen my friends and colleagues with great care. I trust your judgment and feel grateful that you have agreed to carry out my wishes. Thank you.

Signature: _________________________________ Date: ___________
Disclaimer: This information does not represent legal advice and should not be relied upon as such. As with all matters, check with an attorney practicing in your state to insure that the recommendations in this article do not run contrary to your state's laws. 
Note: This document is copyrighted. It is being made available without charge for personal use to individuals. Commercial use including reproduction, or use by organizations and for-profit businesses is prohibited without the author’s written consent. 

© Copyright Ann Steiner, Ph.D., 2000 Purpose: This form is designed to include information that your ERT should have before they place calls to cancel your appointments. It is intended to be used as a template that you can modify to meet the particular needs of your practice.

Suggestion:  Keep updated copies of this form in a separate file labeled Client Contact Summary Sheets, and a copy in each client’s file.  Maintaining these forms will make it easier for your ERT to get current client phone numbers and essential client information.  

Client Contact Summary Sheet
Name of Client:		Date first seen:							
									
Phone numbers: (Check which phone client prefers to receive messages)									
Home phone:		OK to leave a message?	Yes		No				
Work phone:		OK to leave a message?	Yes		No				
									
Treatment modality:									
Individual		Couples		Family		Group			
									
Frequency of sessions:	Weekly		Bimonthly 		Other				
									
Name and phone numbers of emergency contact people to be notified in case of crisis, i.e.: 									
Family member	Name:		Phone:						
Primary physician	Name:		Phone:						
Psychiatrist	Name:		Phone:						
									
Diagnosis:									
Axis I:									
Axis II:									
Axis III:									
Axis IV:									
Axis V:	 Current GAF	  	  Highest in past year	  					
									
History of psychiatric hospitalizations and crises: 									

									

History or current risk of self-injurious behaviors, suicidality, danger to others?	Yes		No						
If yes, summarize danger:									

Summary of client goals, progress and nature of transference: 									

									

									
									
Summary of group themes and challenges:									

									

List of medical and psychiatric medications, with notation regarding any that may affect client’s response to loss of therapist						
Medication	Dosage	Prescribing Physician	Date Started			

						

If multiple medications, list on back side of this page						
						
Other drug use, i.e. Alcohol, Marijuana, Caffeine, Tobacco, Psychedelics, Methamphetamine, Heroin:						

						
Other providers, i.e. psychiatrist, significant medication issues and complications that may arise:						

						
						
Potential for legal action?	Yes		No			
If yes, briefly describe:						

						
						
Recommend that file be retained indefinitely?	Yes		No			
Summary of clients’ history with termination:  						

						

						
						
Suggestions for Bridge Therapist or ERT re therapist illness or death, include names of therapists likely to be a good match for client in your absence:						

						

Additional comments:						

						

Date updated:						

Checklist of Information Needed by Emergency Response Team

	ERT, attorney and professional executor have latest copy of your Guidelines for the Disposition of My Psychotherapy Practice and malpractice face sheet.
	List of active cases, updated yearly, ideally - include supervisees, consultees, and appointment times. Identify complex cases, highlight clients at risk of suicide.
	Client and group summaries, vital information about each client, including where to leave a confidential message.
	Recommendations for interacting with specific individual clients and group members.
	List of former clients from the prior year and significant former clients.
	Two sample letters, plus blank letterhead, that your ERT can send to clients to inform them of your death or temporary absence. 
	Location and instructions for disposition of manuscripts, teaching files, lectures, books, journals, or tapes.
	Directions for retrieving and changing the outgoing message on your office answering machine.
	Suggested Outgoing Answering Machine Message.
	Detailed directions regarding location of office and file cabinet keys, computer passwords, and other essential codes.
	List of Preferred Referral Therapists.
	Wishes and directions regarding memorial, including suggestions for groups.

References:

Becker, E.  The Denial of Death, The Free Press, New York, 1975.

Chernin, P. (1976) Illness in a Therapist – Loss of Omnipotence, Archives General Psychiatry, Vol. 33, Nov., p. 1327.

DeWald, P. (1982) A Serious Illness in the Analyst: Transference, Countertransference, and Reality Reponses, Journal of Psychoanalytic Association. Vol. 30, No 2, p.347.

Gerson, B. The Therapist as a Person: Life Crises, Life Choices, Life Experiences, and Their Effects on Treatment, The Analytic Press, 1996. 

Guy, J., Souder, J. (1986) Impact of Therapist’s Illness or Accident on Psychotherapeutic Practice: Review and Discussion, Professional Psychology: Research & Practice, Vol. 17(6) p. 509.

Halpert, E.  (1983) When the Analyst is Chronically Ill or Dying, Psychoanalytic Quarterly, 1.1.

Ireland, M.  Plan for a Professional Will in the Event of Illness, Disability, or Death, unpublished manuscript, 1998.

Kahn, F. (1998) Ending A Clinical Practice in The Event of Disability, Retirement or Death, California Psychologist, April, p. 89.

Levin, D. (1998) Unplanned Termination: Pain and Consequences. Journal of Analytic Social Work. Vol. 5(2) p. 35.

Rauch, E. (1998) A One Session Memorial Group Following the Death of a Therapist,  International Journal of Group Psychotherapy, 48 (1) p 99-104.

Rutzky, J. (2000) Taking Care of Business: Writing a Professional Will, The California Therapist, Vol. 12 (4), p. 44.

Samuels, L.  When the Analyst Cannot Continue, The San Francisco Jung Institute Library Journal, Vol. 10, No. 4, 1992, pp. 27-38.
 
Schad-Somer, S. (1985) Situational Countertransference, Journal of Contemporary Psychotherapy. Vol. 15(2) pp.156. 

Schwartz, H., Silver, A. Editors, (1990) Illness in the Analyst: Implications for the Treatment Relationship, Madison, CT, International Universities Press.

Steiner, A. (2002) The Emergency Response Team: A Back Up Plan Every Clinician Needs The California Therapist, April/May, p. 69-77.

Steiner, A. (2001) When the Therapist Has to Cancel The California Therapist, Jan/February, p. 52-54.