Heritage Service Dogs
85610 McDaniels Rd
Milton Freewater, OR 97862
Dear Health Care Provider:
Heritage Service Dogs is a cross-disability organization, providing training and placement for physical, medical intellectual and emotional support dogs. Our agency is assisting to secure the necessary documentation per the ADA, HUD and ACAA requirement. This information may be required specifically for housing, employment or air travel.
The ADA definition of a "disability" is: “A physical or mental impairment that substantially limits one or more of the major life activities of an individual”. Major Life Activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working. A major life activity also includes the operation of a major bodily function, including but not limited to, functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions. ADA 2011
If your patient meets the ADA criteria, the information below is all that is needed. It is not necessary to list the specific diagnosis, or potential benefits an emotional support animal or a service dog could provide for this person.
Thank you for your assistance in providing the requested medical documentation for this patient. If you have any questions feel free to contact me.
This can be copied on Clinic letterhead.
Patient Name: ________________________________________________________________________
To Whom It May Concern:
1. The person listed above does have a disability, physical or mental impairment that substantially limits one or more major life activities.
2. An emotional support or service dog may provide assistance, perform tasks or services for the benefit of this person with a disability, or provide emotional support that alleviates one or more of the identified symptoms or effects of this person's existing disability.
Health Care Provider Information
License #: _____________________________________________________________________
Signature: ________________________________________________ Date: ________________
To determine what an emotional support animal or a service dog might do to help with a particular disability, make a list of those things you cannot do for yourself because of your disability. Consider what someone else is doing or might do to help you overcome these barriers to basic functioning.
Service dogs are specifically trained to perform tasks that mitigate their handlers’ disability/disabilities. These are things that the handler cannot do for themselves but must be able to do in order to function appropriately.
This mitigation can be in the form of:
·Alert handler to impending exacerbation of symptoms
·Wake up handler and/or other care giver to alarms or alerts
·Remind handler of treatment or medication
·Retrieve medications, testing supplies, or telephone
·Provide a grounding/calming effect to minimize the severity of an episode
·Provide tactile stimulation to interrupt repetitive or harmful behaviors
·Provide deep pressure or warmth therapy
·Find help when needed
·Guide handler safely
·Provide visual and/or auditory alert
·Turn lights off and on
·Open and close doors
·Provide stability and support for balance
·Brace for standing or transferring
·Mobility assistance with chair
·Stabilize handler prior to and during an episode
·Physically engage handler to revive them after an episode
·Provide an accurate indication of danger and the lack thereof
·Help locate exits or lead handler out of a situation
·Create personal space around the handler
·Block handler from traffic or other dangers they may not be aware of
·Alert to substances that cause life threatening allergic response
·Retrieve assistive devices
There are many physical, medical and psychiatric conditions that service dogs are able to assist with.
·Attention Deficit Disorder, Attention Deficit Hyperactive Disorder
·Dissociative Identity Disorder
·Dizziness, balance problems
·Physical Impairments, Weakness
·Postural Orthostatic Tachycardia Syndrome
·Post-Traumatic Stress Disorder
·Specific Learning Disabilities
·Traumatic Brain Injury
This information was created to help get the documentation required for specific use of a service dog. This may include housing, employment or airline travel. Our clients are welcome to copy and use this information for this purpose.