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Emotional Support Animals

anthonymtrezza

Updated: May 23, 2024

Have you ever been asked, “I need a letter for my emotional support animal.”


It is a tricky treatment recommendation. It may result in benefit for your client, but is it in everyone’s best interest?


First, there is a difference between a support animal and a service animal. However, people will interchange the terms or use a general abbreviation ESA, which is not clear. 


A service animal has been specially trained for a condition such as differing abilities of sight and hearing, epilepsy, or PTSD. Service animals must be a dog or miniature horse. The canines are incredibly expensive: usually $20,000 minimum but could be as much as $60,000. In addition, they have expensive monthly maintenance costs too. I have never met someone, let alone a client or patient, who had a service animal. In the state of Connecticut, such dogs have orange leash and collar, or special harness. They may also have a tattoo on their ear flap, a special coat to wear, and puppies may wear special bananas.


Clients usually request an order for an emotional support animal for the following reasons:


  1. Housing: They are not allowed to have a pet at their rental home, but request a medical exception by law.

  2. Community: They request to bring the pet into the locations that don’t usually allow animals, but believe it will help with an anxious process. 

  3. School: They request to arrange to have a pet at school, in some capacity to help with a behavioral issue. 



Housing: According to the federal Fair Housing Act, services animals and  emotional support animals are allowed in a ‘no pet’ rental agreement. However, the individual must have a disability and the animal must provide relief for that disability. For an APRN, we need a diagnosis and then a reason as to why the animal would help with those symptoms. The landlord cannot charge any extra fee for having the ESA. However, any damage to the home by the animal is subject to fee. You should also obtain an ROI for the respective housing authority/landlord too. Also, your letter of an ESA for disability may exempt the pet owner from paying move-in pet fees or monthly pet fees. 


Community: There is no accommodation under the ADA for emotional support animals in the community. Theres is no Connecticut law that provides any accommodation for emotional support animals. As an APRN, you still have the right to complete a recommendation letter identifying the client, the animal, and its use. A business or location still has full legal right to deny the patron. I think there are some issues with these letters though. For example, there are potential HIPAA concerns with a generic psychiatric letter being shown throughout the community. I think it is important to question how such a letter (with your name) will be used. I could see a client with agoraphobia or intense social anxiety benefiting from such a letter. In those regards, it could be considered a ‘good faith’ intervention. But, could it be used inappropriately? I have witnessed people misrepresent their pets in public. But, for what purpose? Is it always for an essential therapeutic need? Ask yourself, “Is this going to be utilized and gain emotional progress?” I think it is important to conceptualize how this client or family intends to use the therapy.


School: I have written letters for emotional support animals for school. I have tried it as a “last ditch effort” for youth with excessive absenteeism. It has never worked. It becomes a blunder. The animal/dog comes to the school for a brief part of the day. The student is usually in their own room with the animal, while it barks away. There are pet dander concerns for the other studentos and staff. Its presence disrupts the school day for other students. If the dog has an accident, the parent or student may expect the school to clean things up. When the dog leaves, the student doesn’t want to be at school anymore. In my experience it serves as a novelty, and not really a therapeutic tool. Suffice it to say, I do not write these letters anymore. In fact, I find that the schools have gotten fed up with ESAs. Many school districts have written “No ESA” policies. I think the best option is to approach the school directly. Inquire if they are comfortable or open to bringing in a therapeutic animal with a trainer to the school. Some schools are looking into creating a dog therapy program, where others are not making this a priority. Lastly, if we genuinely want to utilize an animal for therapeutic needs, review and create a clear therapy plan. Specifically. when, where, and why is the animal therapeutic. Keep in mind there are also equestrian therapy centers. Many of these do not accept insurance.


Let’s talk more in detail about ESA dogs. If you plan to write a letter for any reason, consider a thorough assessment and documentation of the dog. Inquire if the dog has ever attacked anyone. If it has a history of dangerousness, do not complete letter  because you may make yourself liable and place others in jeopady. Inquire about the breed of the dog. I do not complete a letter unless I get a clear answer on the breed. Maybe a client wants a loving support Rottweiler for their home. Could there be potential liability? 


Imagine that you write a letter recommending an ESA for a client. Maybe this client lives in an apartment complex that does not allow dogs, or certain breeds of dogs. Your letter supersedes their rules on permitted breeds of dogs. The client is now allowed to have this breed of dog that you knowingly, or unknowingly, recommended. Four years later, the dog bites someone or worse. Your letter is going to indicate that this dog is an ESA. Are you responsible?


A well-known case in Portland, Oregon:


Due to dog attacks by ESAs,  airlines have stopped allowing them on airlines. 



I found countless websites from legal teams wanting to represent dog bite victims, specifically from an ESA. This must be a common phenomenon for legal action. 



A list of dogs that are not covered by insurances:



APRNConnect ESA Assessment:


  1. Assess for Disability Diagnosis

  2. Do the symptoms legitimize efficacy for recommending ESA?

  3. Conceptualize if the ESA will be used inappropriately

  4. Are they able to financially and competently care for the animal’s needs? Are Vaccines up-to-date?

  5. What is the name of the animal?

  6. Confirm how many animals.

  7. If this is a dog, what specific breed mix?

  8. Does it have a history of aggression or attacks?

  9. Does your letter require an expiration date? The need for future re-assessment?


APRNConnect ESA Recommendations:

  1. Indicate the F Code & Diagnosis

  2. Indicate the symptomatic need for an ESA

  3. Note the name and breed of each animal

  4. Indicate the Vet and last appt and that vaccinations are up-to-date

  5. Indicate there is no history of aggressiveness

  6. Put a 12-month expiration date on the letter and reassess at that time

  7. If you cannot complete this information, simply explain that it is not ethical to complete such a medical letter or order.




Fun Fact: Courthouses have used “comfort dogs” for testifying witnesses. 


PS: I really like animals and believe they can be therapeutic. 

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