Have a client that wants an ESA letter?

INSTRUCTIONS FOR PROVIDER

If you have a client who wishes to be assessed for an Emotional Support Animal (ESA) letter, please go through the following pre-screening checklist with the individual prior to referring them for an ESA assessment. You may also download it as a PDF to complete in your next session. After the screening is complete, fill out the form!

If you believe the individual reasonably meets criteria detailed in this checklist:

  • Provide the individual with my contact information so they may review costs, policy/procedure, timeframe for the process, and schedule their first appointment if they wish.

  • The individual may choose to sign a Release of Information form for you to be able to release treatment records or a summary to me. Please do not send treatment records until requested, however, as I want to make sure I have a file opened for the individual prior to receiving any records.

  • When treatment records are requested, include this completed form with your records disclosure.

PRE-SCREENING CHECKLIST

Criterion A: Disability

  • The individual is aware that they are being referred for a mental health-related disability assessment.

  • The individual has a physical or mental impairment which substantially limits one or more major life activity. Major life activities can include, but are not limited to: caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.

  • The individual has a current diagnosis on-file which has moderate to severe symptomology and does not have primary diagnosis of: Adjustment Disorder, V-Codes, and/or Unspecified Disorders. (If any of these diagnoses are listed as primary, they are exclusionary; however, they may be listed as secondary diagnoses.)

  • The individual’s primary diagnosis is not a Substance Use Disorder and the individual is not actively using/abusing illicit substances. This is exclusionary, although they can be referred if currently in recovery from substance use. 

  • The individual is not regarded as being a juvenile offender or a sex offender, and the individual is not regarded as being a direct threat to others. (These are disability exclusions.)

Criterion B: Animal

  • The individual denies a personal history of animal mistreatment or abuse.

  • The individual is aware that they, themselves, are being assessed and not their animal(s).

Criterion C: Treatment Records (optional)

  • It is recommended that the individual requests that their provider(s) furnish treatment records or a treatment summary to help confirm their diagnosis and functional impairment(s). Note: This is not required; however, it does help substantiate, and possibly expedite, the assessment.

Important Notice: No guarantees

  • Only basic information is covered here; many more aspects will be considered in the assessment.

  • ESA Letters and/or accommodations are not guaranteed. ESA Letters will only be issued when the assessment reveals that all criteria have been met. There is a chance that an ESA letter may not be indicated nor issued to the individual. There is also a chance that accommodations may be denied even with an ESA Letter. Refunds for services rendered are not available regardless of whether an ESA letter is/is not issued and/or accommodations are/are not extended to the individual.