Emotional Support Animal (ESA) Evaluation & Consent

# Emotional Support Animal (ESA) Evaluation & Consent This document memorializes the informed-consent process and clinician's evaluation for an Emotional Support Animal letter request. It is entered into as of ___________ by and between: **Client:** ___________, residing at ___________ ("Client"); and **Provider:** ___________, a licensed ___________, License Number ___________, licensed in ___________, with a practice address of ___________ ("Provider"). --- ## 1. Nature of the Therapeutic Relationship Client and Provider have an established therapeutic relationship that commenced on or about ___________. The nature of the relationship is: ___________ Provider's evaluation for ESA purposes is based solely on Provider's independent professional clinical judgment arising from this relationship, not on Client's request alone. --- ## 2. Client's Mental Health Information (for Provider's Records) *This section is completed by Provider and retained as a clinical record. It is not transmitted to landlords or third parties.* **DSM-5 / ICD-10 Diagnosis or Clinical Presentation relevant to this request (Provider's assessment):** ___________ **Functional limitations identified that may be addressed by an ESA:** ___________ **Provider's assessment of whether an ESA is clinically appropriate for this client:** ___________ **Basis for assessment:** ___________