CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS 

Office of the Chief Medical Officer 
Clinical Operations 


Toolkit: Evaluating a Client's Need for an Emotional Support Animal

SC-01
 
Category: Special Considerations
Published Date: March 2024
  1. PARAMETER GOAL
     
    1. To provide health care practitioners with information and resources for evaluating a client's need for an emotional support animal.
       
  2. TERMINOLOGY
     
    1. Assistance Animal: An animal that works, provides assistance, or performs tasks for the benefit of a person with a disability, or that provides emotional support that alleviates one or more identified effects of a person’s disability. An assistance animal is not a pet (Fair Housing Act).
       
    2. Emotional Support Animal (ESA): An animal that does not need to be trained or certified and provides emotional, cognitive, or other similar support to an individual with a disability.
       
    3. Guide/Service Dog: Any dog trained to perform tasks for the benefit of an individual with a disability.
       
    4. Health Care Practitioner: A DMH employee who is licensed, regulated, and acting within the scope of practice of their license or certificate in accordance with California BPC Division 2.
       
    5. Service Animal: A dog, regardless of breed or type, that is individually trained to do work or perform tasks for the benefit of a qualified individual with a disability, including a physical, sensory, psychiatric, intellectual, or other mental disability.  Animal species other than dogs, emotional support animals, comfort animals, companion animals, and service animals in training are not service animals (Air Carrier Access Act).
       
  3. ASSESSMENT
     
    1. Establish rapport with the client for a minimum of 45 days.
       
    2. Identify the reason for the letter request (why now?)
       
    3. Complete a biopsychosocial assessment
      1. Obtain a comprehensive mental health history
        1. Outpatient mental health treatment
        2. Psychiatric hospitalizations
        3. Trauma history
        4. Substance use
        5. Medical conditions
        6. Environmental factors
        7. Education/employment
        8. Legal status/involvement
        9. Family/social factors
        10. History with pets 
      2. Mental status exam
        1. Mood/affect
        2. Thought processes
      3. Describe factors of the symptoms/behaviors that an ESA would improve or maintain/stabilize:
        1. Intensity 
        2. Duration
        3. Onset
        4. Frequency
        5. Impact on quality of life 
      4. Client strengths
        1. Protective factors
        2. Coping skills
      5. Develop an understanding of the client's need for an emotional support animal
        1. Is this a new pet?
        2. Do they have a pet now?
        3. How long have they had the pet?
        4. How have they managed with symptoms thus far?
        5. What is the plan to reduce dependence on the pet?
           
    4. Establish a DSM diagnosis
      1. If there is no diagnosis, what alternatives beside an ESA have been used/implemented/explored?
         
    5. Justification for letter for ESA
       
    6. Ability to care for an ESA
      1. Become familiar with pet ownership laws in California (Can the client care for the animal including feeding, registration of dogs, assume liability for behavior of animal?).
         
  4. SERVICE
     
    1. Health care practitioners are prohibited from providing documentation relating to an individual’s need for an ESA unless they:
      1. Hold a valid, active, license to provide professional services within the scope of the license in the jurisdiction where the documentation is provided;
      2. Establish a client-practitioner relationship with the individual for at least 45 days prior to providing the documentation;
      3. Complete a clinical evaluation of the individual regarding the need for an ESA;
      5. Provide notice to the individual that knowingly and fraudulently representing oneself to be the owner or trainer of any canine licensed as, to be qualified as, or identified as, a guide, signal, or service animal is a misdemeanor.
         
    2. Elements that support a letter:
      1. A health care practitioner who provides a client with a letter for an ESA will provide written notice, in at least 12-point bold type and on a receipt or separate paper, stating that:
        1. The animal has not been evaluated and this letter does not certify the animal in any way.
          1. The animal does not have the special training required to qualify as a guide, signal, or service dog;
          2. The dog is not entitled to the rights and privileges accorded by law to a guide, signal, or service dog; and
        2. Knowingly and fraudulently representing oneself to be the owner or trainer of any canine licensed as, to be qualified as, or identified as, a guide, signal, or service dog is a misdemeanor.
           
    3. Discuss with the client the privacy implications of writing a letter on Department letterhead.
      1. Anyone with whom the client shares the letter will be aware of their mental health status.
         
  5. TRAINING
     
    1. Know the difference between an emotional support animal and a guide/service dog
      1. ESAs are NOT service animals. They are not trained to perform specific acts related to a person’s disability. The owner of an ESA derives a sense of wellbeing, fulfillment, companionship, or lessened anxiety with the presence of the animal; however, ESAs do not have the same legal privileges as trained service dogs. For example, while federal and state laws require that service dogs be allowed to accompany their human partner in public places, ESAs do not have to be accommodated.
      2. The emergence of ESAs has led to an increase in the fraudulent selling and subsequent misrepresenting of emotional support dogs as service dogs. Businesses are selling misleading ESA-related certificates and merchandise that inaccurately imply that ESAs have the same legal rights and privileges as service dogs.
         
    2. Health care practitioners are not evaluating or certifying the animal. 
       
    3. Consequences
      1. Violating the requirements of HSC § 122318 subjects the health care practitioner to discipline from the licensing board.
      2. A person who knowingly and fraudulently represents a dog as a guide, signal, or service dog, can be found guilty of a misdemeanor punishable by imprisonment in the county jail not exceeding 6 months, by a fine not exceeding $1,000, or by both.
      3. Violation of these written notice requirements or knowingly and fraudulently representing, selling, or offering for sale, or attempting to represent, sell, or offer for sale, an ESA as being entitled to the rights and privileges accorded by law to a guide, signal, or service dog, is subject to a civil penalty of $500 for the first violation, $1,000 for the second, and $2,500 for third and subsequent violations.
         
    4. Courses:
  6. SUPERVISION AND CONSULTATION
     
    1. DMH requires that health care practitioners obtain supervisor approval prior to providing clients with a letter for an ESA.
       
    2. Health care practitioners should seek additional guidance and proper consultation before making a decision about providing a client with a letter for an ESA or when faced with any ethical dilemma, including: 
      1. Relevant literature on professional ethics and ethical decision-making
      2. Agency-based or professional organization’s ethics committee, a regulatory body, knowledgeable colleagues, supervisors, or legal counsel.
         
  7. RESOURCES