If the client is under 18 years old you will be required to describe your relationship to the client at the end of the emotional support animal informed consent form.

Definition of Emotional Support Animal

An emotional support animal (ESA) is a domesticated animal of any species that provides therapeutic benefit through companionship with a person who experiences a distressing mental health diagnosis as defined by the Diagnostic and Statistical Manual of Mental Disorders, Version 5 (DSM-5-TR) that significantly limits functioning in one or more areas of life (also referred to as a psychiatric disability).

An ESA, in contrast to a service animal, is not specifically trained to perform a specific task(s). Additionally, ESAs are not protected under the Americans with Disabilities Act (ADA) which was enacted to prevent discrimination based on disability.

According to Ohio law, an ESA may be used as an accommodation for housing purposes only. ESAs cannot be taken into stores, on airplanes, libraries, schools, restaurants, or other places of business.

Benefits & Risks of ESA

The possible benefits of having an ESA include the following:

• Alleviation of distressing mental health symptoms
• Improved physical and psychological well-being
• Increased sense of social support provided by, and facilitated by, the ESA
• Once an ESA is declared necessary, the ESA is no longer regarded as a “pet”; therefore, all pet fees at the residing residence should be seized after the ESA is verified.

The potential risks of having an ESA include the following:

• Clients must be aware that some identifying information is necessary to verify the need for an ESA. Information that may be necessary includes the client’s name, diagnosis, date of first visit with a provider, provider’s name, animal’s name, animal’s birthday, and name of the animal’s vet or behavioralist.
• All costs associated with owning and caring for an animal should be taken into consideration.
• Each animal is different. Some require more care than others, which should be taken into consideration when choosing an animal as an ESA.
• Clinical providers are mandated reporters of animal abuse.
• Stressors associated with pet ownership, and the potential negative psychological impact of pet loss.

Consent to ESA Letter Writing Services

I consent to meet four basic requirements for a trained provider at Wellness Grove to provide a face-to-face (virtual or in-person) evaluation for an ESA:

1. A biopsychosocial assessment that includes determining whether there is a psychiatric condition that significantly limits functioning in one or more areas of life (also referred to as a psychiatric disability)
2. An assessment, based on clinical expertise and training in the area of ESA support letter writing, that determines whether the ESA will alleviate impairments in functioning that have been identified
3. An assessment, based on clinical expertise and training in the area of ESA support letter writing, that determines the practical and mental capacity need to care for an ESA
4. As assessment, based on training in the area of ESA support letter writing and the gathering of collateral information, that the animal has the capacity to serve in the role of an ESA

Further, I understand that:

• I am responsible for providing support that the animal has the appropriate disposition, temperament, and/or training needed to serve as an ESA. Behavior verification, or a behavior assessment, may be provided by an animal behaviorist or veterinarian. Attesting to an animal’s behavior or safety is beyond the clinical provider’s scope of practice and should be assessed by a qualified professional with accompanying documentation.
• I have informed my landlord or residence provider of the existence of the animal before a letter has been written.
• I am responsible for being honest about the effectiveness of the ESA relationship.
• I am responsible for ensuring proper care for the ESA including, but not limited to, their financial, medical, and living needs.
• I am responsible for continuing therapy with the clinical provider who is writing the letter to continue verification of the effectiveness of the ESA benefits.

 

Acknowledge & Sign

I have read and understand the information provided within this Informed Consent Form. I understand that I will have an opportunity to discuss the terms of this consent with my clinician at the start of my counseling session. I acknowledge and agree to present all my questions to my clinician, if any, and to not proceed with my counseling session until all my questions have been answered to my satisfaction. I understand that by continuing my participation in the counseling session I am asserting my understanding and agreement to the information provided in this consent form.

I have read and understand the risks, benefits, and regulations as listed above and understand ESA letter writing is at the discretion of the clinician and is determined by my therapeutic need for an emotional support animal. I hereby agree to having an assessment made regarding my need for an emotional support animal and agree that I assume any risks involved.

I hereby give my informed consent to having an assessment made for need of an emotional support animal and having a letter written at the discretion of the clinician under the terms described herein with Wellness Grove.