Psychiatric Animal Support Form PDF Details

Animals can offer incredible support to individuals struggling with mental health. From the comfort of a housepet, like a dog or cat, to more specialized therapy animals like horses and dolphins, there are countless ways that animals can positively affect someone's wellbeing. At ABC Psychiatric Services, we understand this connection and strive to provide a variety of animal-assisted interventions as part of our psychiatric treatment plans. To ensure the safety and quality of care for both patients and their animal companions, we have developed the Psychiatric Animal Support Form which documents any patient who wishes to bring an animal into their session. This form will help us create a safe environment where you can feel surrounded by your own four-legged friend(s) during your recovery journey!

QuestionAnswer
Form NamePsychiatric Animal Support Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesanimal support letter, fillable certificates for emotional support animal, therapeutic emotional authorization printable, psychiatric therapeutic united

Form Preview Example

Psychiatric/Therapeutic/Emotional Support Animal Authorization

General information:

Pursuant to the Department of Transportation (DOT) guidance for the carriage of service animals, United requires a passenger with a qualified disability traveling with a psychiatric/therapeutic/emotional support type animal to obtain documentation from their medical/mental health professional.

•This form is valid for one year from the date the licensed medical or mental health professional treating the person has signed this form.

•Other documentation may be required for travel entering or exiting an international location.

•Service animals must be properly harnessed for the duration of the flight. Small animals may remain in the passenger’s lap during the flight. If a carrier will be used, it must meet the USDA guidelines and fit under the aircraft seat.

Instructions:

 

Medical/Mental Health

 

Professional:

Please complete this form or provide the passenger with a written statement containing the information on

 

this form on your practice letterhead.

Passenger:

Send a copy of the form or written statement to the United Airlines Accessibility Desk by fax (872-825-

 

0208) or email (uaaeromed@united.com) 48 hours prior to travel for documentation verification (by

 

contacting your health care professional). Please retain the original form or your medical/mental health

 

professional statement in your possession while traveling and be prepared to present it to airline

 

representatives.

Accessibility Desk:

Verify documentation. Complete SSR in the PNR with ESAN APPROVED or NOT APPROVED and your

 

name.

Airport Agent:

Verify the passenger’s documentation and SSR information in the PNR. Verify the animal meets the

 

requirements (i.e., behavior) to travel in the passenger cabin free of charge.

Note: With respect to an animal used to assist a qualified individual with a disability, the animal must be trained to behave appropriately in a public setting. Animals found not to have been trained to behave will only be accepted in accordance with United’s current pet policies or may be denied boarding.

Initial

 

Must be completed by Medical/Mental Health Professional

 

 

 

 

 

 

I certify that the passenger has a mental health-related disability listed in the Diagnostic and Statistical Manual of Mental

 

 

 

 

 

 

Disorders (DSM-5).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Having the animal accompany the passenger is necessary to the passenger’s mental health or treatment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am a licensed medical/mental health professional treating the passenger’s mental or emotional disability.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The passenger is under my professional care.

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical/Mental health professional’s license information:

 

 

 

 

 

 

Date and type of the license:

 

 

 

 

 

 

 

 

License Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State or other jurisdiction in which license was issued:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your Name (print):

 

 

 

 

 

 

Signature and Date:

 

 

 

 

 

 

Business Phone Contact:

 

 

 

 

 

 

 

 

 

 

 

 

 

Passenger/Patient Name (print):

 

 

 

 

 

 

 

 

 

 

 

 

 

Animal Type, Breed and Weight:

 

 

 

 

 

 

 

 

 

 

 

 

 

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How you can complete animal authorization united form step 1

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animal authorization united form conclusion process detailed (part 2)

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