What’s in a disability service animal/ESA letter?
If you decide to write a letter advocating for your patient to have a service animal or ESA, the letter should appear on letterhead, be written by a licensed mental health professional, and include the following2,20:
- statement that the letter is being written at the patient’s request and is being given directly to the patient for use as the patient sees fit
- confirmation of the patient’s DSM-5 mental health diagnosis
- explanation of how the animal helps alleviate symptoms of the patient’s condition, briefly describing any interaction(s) between the animal and patient that you may have observed, and if applicable, a mention of any training the animal may have received from a qualified trainer if applicable
- explanation of the possible negative effects of the patient not having the animal with him or her
- statement that you are not vouching for the animal’s behavior
- verification of your involvement in your patient’s treatment and your assessment of the patient as their licensed mental health professional (including details such as date and type of license you have and the state/other jurisdiction where it was issued).
In a letter for a service animal, also indicate that your patient is psychiatrically disabled to the extent that your patient is not able to perform at least one major life task without the daily assistance of a service animal.2Should you write your patient a letter?
Writing a letter advocating for a patient to have a service animal or ESA may appear innocuous, but doing so may have serious ramifications. Writing a letter certifying a dog as a service animal does not make that animal a service animal; the dog must be specifically trained for a task or tasks directly related to that individual’s disability. There are no current standards for conducting evaluations to determine the need a patient has for a service animal or ESA. How to conduct such evaluations is beyond the scope of this article. There are meager opportunities for formal education and training on how to conduct these evaluations.9 Online resources may be incomplete or inaccurate, and this information is often produced by lay animal enthusiasts and organizations, which can lead to a biased depiction of these animals.9
If you decide to write a letter for your patient, consider the following forensic and ethical concerns.
Remain objective. As an advocate for your patient, you may find it difficult to remain neutral and objective when asked to determine if your patient has a disability, the severity of the disability, the impact of the disability on your patient’s life, and the need for a service animal or ESA. Ensure that your advocacy for your patient does not impair your objectivity; if that is difficult, consider referring your patient to a third party who can conduct an objective evaluation.
Understand the risks. If you make written recommendations for special accommodations in a letter and those recommendations are disputed by an agency, that agency could initiate legal action and you may be called to justify your recommendations in a deposition or open court.9,21 Before writing the letter, ask yourself, “Can I defend my determination that my patient is disabled by a DSM-5 disorder and that this disability requires the presence of an animal in exception to existing policy?”21 Be prepared to state in a legal proceeding that the presence of a service animal or ESA is necessary. If you are unwilling to risk exposure to a legal action, then you should likely refrain from writing the letter. It is a crime to fraudulently certify an animal as a service animal in some jurisdictions, and such conduct could result in disciplinary action by your licensing board.21
Conduct a systematic examination. When you write a letter for your patient, you are explicitly declaring your patient has a disability or condition. Comprehensive disability determinations are complex and are best conducted by assessing for objective evidence of psychiatric disorders and impairment through the use of standard, systematic examination methods.22 Unstandardized measures (eg, asking patients open-ended questions and then relying on your clinical judgement and interpretation in arriving at conclusions) are not as effective.22 In addition, consider the possibility that your patient may malinger their symptoms in an effort to obtain a letter supporting a service animal or ESA. Assessing for malingering is essential to making a disability determination, especially if a disability claim is based primarily on self-report.22
Anticipate pushback. Problems can arise when a patient wants a letter that you cannot or will not provide due to your scope of practice. Consider how you would resolve the situation when you do not believe your patient has a disability that requires the presence of a service animal or ESA—or you believe that your patient no longer needs a service animal or ESA—and the patient disagrees.21 Disagreeing with your patient’s assessment could result in a conflict of interest that could damage the therapeutic relationship.21
Box 2
Legal protections for service animals and emotional support animals
The Americans with Disabilities Act (ADA) of 1990, as amended by the ADA Amendments Act of 2008, prohibits discrimination on the basis of disability in several areas, including state and local governments (under Title II of the ADA) and places of public accommodations, commercial facilities, and private entities (under Title III of the ADA).6,7 Thus, individuals with disabilities can bring their service animals into the building or facility where members of the public, program participants, clients, customers, patrons, or invitees are allowed.2 This does not include private clubs not open to the public, religious organizations, or places of worship.6,7
Service animals. Although the ADA recognizes miniature horses as service animals, only dogs are recognized as service animals in regards to Title II and Title III protections under the ADA as of March 15, 2011.2 Federal agencies do not have to comply with the ADA1; however, Section 504 of the Rehabilitation Act of 1973 is the federal law that protects the rights of people with disabilities to participate in federal programs and services.1,8 It states that no qualified individual with a disability shall be excluded from, denied the benefits of, or be subjected to discrimination under any program or activity that receives federal funding or is conducted by federal agencies.8 Courts have strived to interpret the Rehabilitation Act and the ADA in a consistent manner, specifically applying the ADA regulations regarding service animals (including its narrow definition regarding specifically trained tasks and emotional support) to the Rehabilitation Act.9-11
Similarly, commercial airlines do not have to comply with the ADA1 ; however, the Air Carrier Access Act (ACAA) of 1986 is the federal law that protects the rights of people with disabilities in air travel.1,12 On December 2, 2020, the US Department of Transportation announced that it was revising its ACAA regulation regarding service animals on aircraft (this final rule will be effective 30 days after date of publication in the Federal Register).13 Among the many revisions, the US Department of Transportation narrowed the definition of service animals to only dogs that were individually trained to work or perform tasks for the benefits of a person with a disability.13 It requires airlines to treat psychiatric service animals the same as other service animals.13 Although the US Department of Transportation has chosen to closely align its ACAA service animal definition with US Department of Justice service animal definition under the ADA, the substantive requirements in this final rule differ from US Department of Justice’s requirements for service animals under the ADA in various areas (for example, by allowing airlines to require service animal documentation and prohibiting the use of voice control over a service animal).13
Emotional support animals. Regulations regarding ESAs are primarily set by individual states1,3; however, ESAs may qualify for a waiver of a no-pet rule or a pet deposit under the Fair Housing Amendments Act (FHAA) of 1988.2,14 Under the FHAA, if an individual has a disability, as defined by the ADA, that requires the presence of an ESA, or if they have symptoms that are ameliorated by the presence of an ESA, the landlord must comply with this request and allow the animal into the facility without charging pet fees.15
Bottom Line
Disability service animals and emotional support animals (ESAs) differ in their roles and legal protections. Before writing a letter in support of a patient’s request for a service animal or ESA, take into account the forensic and ethical implications of doing so.
Related Resources
- US Department of Justice. Civil Rights Division. Disability Rights Section. ADA requirements. Service animals. Updated February 24, 2020. https://www.ada.gov/service_ animals_2010.htm
American Veterinary Medical Association. Service, emotional support and therapy animals. https://www. avma.org/resources-tools/animal-health-welfare/ service-emotional-support-and-therapy-animals
US Department of Transportation. US Department of Transportation announces final rule on traveling by air with service animals. https://www.transportation.gov/briefingroom/us-department-transportation-announces-finalrule-traveling-air-service-animals