Prescription for Emotional Support Animal
Prescription for Emotional Support Animal
Date: October 8, 2055
Patient Information:
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Field |
Sample Content |
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Patient Name: |
Ellis Bednar |
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Age: |
28 |
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Address: |
Richmond, CA 94801 |
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Contact Number: |
222 555 7777 |
Provider Information:
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Field |
Sample Content |
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Provider Name: |
[YOUR NAME], Licensed Mental Health Professional |
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License Number: |
LMHP-2055-12345 |
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Practice Address: |
[YOUR COMPANY ADDRESS] |
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Contact Number: |
[YOUR COMPANY NUMBER] |
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Email: |
[YOUR EMAIL] |
Diagnosis and Justification for ESA:
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Field |
Sample Content |
|---|---|
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Diagnosis: |
Generalized Anxiety Disorder (GAD) |
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Symptoms: |
Persistent anxiety, excessive worrying, emotional distress |
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Mental Health Treatment: |
Ongoing psychotherapy, cognitive behavioral therapy, medication management |
Recommendation for Emotional Support Animal (ESA):
As a licensed mental health professional, I have been treating the above-mentioned patient for a qualifying mental health condition. Based on the patient’s clinical needs and in accordance with federal and state laws, I recommend an Emotional Support Animal (ESA) to alleviate symptoms related to their mental health disorder.
Purpose of ESA:
The presence of an ESA has been proven to provide therapeutic benefits by reducing the patient’s symptoms of anxiety, depression, and emotional distress, thus improving their overall well-being.
ESA Specifics:
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Field |
Sample Content |
|---|---|
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Animal Type: |
Dog |
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Animal Breed: |
Labrador Retriever |
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Animal's Name: |
Buddy |
Legal Provisions and Protections:
Under federal law, particularly the Fair Housing Act (FHA) and the Air Carrier Access Act (ACAA), Emotional Support Animals are protected to reside with their owners in housing that may otherwise prohibit pets. Additionally, the presence of an ESA may assist the patient during air travel.
Duration of Prescription:
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Field |
Sample Content |
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Date of Issue: |
October 8, 2055 |
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Duration: |
12 months, subject to renewal |
Provider Signature:
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Field |
Sample Content |
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Provider's Signature |
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Date |
October 8, 2055 |
Notes:
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This prescription is intended to confirm the therapeutic need for an Emotional Support Animal.
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This document does not certify the animal as a service animal as defined under the Americans with Disabilities Act (ADA).
