ESA Questionnaire

PART A: PERSONAL DETAILS - Step 1 of 6

The first step to qualifying for an emotional support animal (ESA) or psychiatric service animal is to fill out the questionnaire, which will only take a few minutes. We will ensure that all your information is kept confidential. We will give a full refund if the licensed therapist establishes that you don’t qualify for the ESA or PSD letter. All the information you share with us will be saved on the server.

Your Official Legal Name *

First

Last

Gender *

Confirmation 18 years old *

I confirm I am at least 18 years old and not acting on behalf of anyone else. *

Date of Birth *

Must be an adult 18+

Email Address *

Confirm Email

Phone Number *

The Emotional support animal you prefer *

e.g. dog, cat and other It is essential to note that the Department of Transportation issue guidance restricting the transportation of unusual animals such as reptiles, rodents, and spiders. Most housing providers will also not be very accommodating of ESAs that are not cats or dogs. Airlines and housing providers are allowed to deny animals that may damage property or pose a threat to other people. Notably, we are not in a position to help individuals who want to accommodate more than 3 ESAs.

Number of animals

At this time, unfortunately, we are unable to assist you if you have more than 2 Emotional Support Animals.

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Have you noticed any changes in your mood for the past 6 months? *

Have you had any of the following emotional and mental symptoms in the last six months?

Difficulty with focus and concentration
Irritability and/or agitation and/or anger
Fatigue
Restlessness
Changes in your sleep (ie., sleeping too much or difficulty falling asleep)
Muscle tension
Depressed mood
Elated mood
Decreased interest in activities that you once enjoyed
Lack of motivation
Changes in your weight (ie., significant weight gain or weight loss)
Changes in your appetite (ie., eating too much or too little)
Feelings of worthlessness or hopelessness
Indecisiveness
Thoughts or wanting to hurt yourself or others
Difficulties with your activities of daily living (eg., preparing meals, paying bills, housekeeping,bathing)
Missing work or school or performing poorly at work or school
Isolation or changes in your social functioning (ie., not spending time with friends/family)
Other
None

In the last 90 days, how often have you been bothered by these symptoms?

Do you often feel sad or depressed? *

How long do you feel sad or depressed on a typical day? *

Less than 1 hour
1-3 hours
3-5 hours
Greater than 5 hours

Do you feel anxious?

For how do you feel anxious on a typical day? *

Less than 1 hour
1-3 hours
3-5 hours
Greater than 5 hours

Do your mental or emotional symptoms interfere with performing normal activities?

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.

If yes, please elaborate on which activities have been interfered with and how?

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Have you on any day experienced intense fear or a reencounter of past traumatic events? *

If yes, kindly indicate if you have experienced any of the following.

Distressing dreams and/or memories of the traumatic event
Flashbacks (ie., feeling that the traumatic event is recurring)
Avoidance of negative memories or thoughts associated with the event
Difficulty remembering important aspects of the traumatic event
Negative thoughts or beliefs about yourself and/or others (eg., “I am bad” or “I can’t trust anyone)
Feeling detached or estranged from others
Difficulty experiencing positive emotions (eg., love, satisfaction, joy)
Reckless or self-destructive behavior
Hypervigilance
Feeling easily startled
Other

In the last 3 months, how often have you been bothered by traumatic events?

Rarely
Moderately
Very Often
Other

Do the symptoms that come from traumatic events affect the performance of everyday activities such as sleeping, eating, and walking, among others?

If yes, how has it affected the performance of everyday activities?

Any past traumatic event you are comfortable sharing with the licensed therapist?

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Have you experienced any intense fear or anxiety in the last 6 months? *

If yes, how often do you get intense fear or anxiety attacks?

Daily
Several times a week
A few times per month
Never
Other

Are you worried about experiencing panic or anxiety attacks in the future?

Did you experience any of the following symptoms during your last panic or anxiety attack?

Increased heart rate
Uncontrollable shaking
Dizziness or nausea
Difficulty breathing
Hot flashes or profuse sweating
Numbness of extremities (legs, fingers, toes, etc.)
None of the above

Do these attacks interfere with everyday life activities such as walking, sleeping, eating, breathing, learning, and working?

If yes, how does the attack interfere with these normal life activities?

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Do you think having an animal can help alleviate emotional and mental symptoms? *

If yes, please describe how you think the animal can help

Have you in the past or currently been diagnosed with any mental or emotional problem?

If yes, which medicine were you given, and for how long have you taken it? *

Write “NONE” if you have not been diagnosed with any illness.

Feel free to share additional information about your current state to the licensed health mental practioner *

Write “NONE” if you have not consumed any OTC or prescription drugs in the last year.

Please use this space to communicate anything else you would like your licensed health professional to be aware of.

Is your ESA for University or On-Campus housing? *

Yes
No
Not sure

Please note if your ESA is for University or on-campus housing, it can be pretty challenging since most facilities are quite strict. You may be required to produce certain documents to be allowed to accommodate your ESA. We can help you, but those extra documents will attract a special fee. Additionally, if the facility denies accommodation of your ESA, we are not in a position to offer a refund. *

I agree with the condition and will like to proceed

Animal Name: *

Animal Type: *

Animal Breed: *

Animal DOB: *

Animal Weight: *

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Discount Code

Please enter your code

Emotional Support Animal Plan select *

Please choose your Emotional Support Animal Plan.

Emotional Support Animal Plan Housing *

ESA Housing - $99.00

• Assessment by a Licensed mental health practitioner • Signed ESA Letter • Submitted to housing providers for ESA accommodation • ESAs should not face residential pet restrictions • Digital Delivery

Emotional Support Animal Plan Housing (10% OFF) *

ESA Housing - $89.10

Emotional Support Animal Plan Housing (100% OFF) *

ESA Housing - $0.00

Emotional Support Animal Plan Housing (99%) *

ESA Housing - $0.05

Emotional Support Animal Plan Housing (85%) *

ESA Housing - $23.85

Emotional Support Animal Plan Housing (15% OFF) *

ESA Housing - $84.15

Emotional Support Animal Plan Housing (20% OFF) *

ESA Housing - $127.20

Emotional Support Animal Plan Housing (25% OFF) *

ESA Housing - $119.25

Emotional Support Animal Plan Plus *

ESA Plus - $119.00

• Assessment by a Licensed mental health practitioner • Signed ESA Letter • Submitted to your housing provider for ESA accommodation • ESAs should not face residential pet restrictions • Digital Delivery • Priority Support • PSD Add-on for $99 • The discounted annual renewal rate of $99

Emotional Support Animal Plan Plus (10% OFF) *

ESA Plus - $107.10

Emotional Support Animal Plan Plus (15% OFF) *

ESA Plus - $101.15

Emotional Support Animal Plan Plus (20% OFF) *

ESA Plus - $151.20

Emotional Support Animal Plan Plus (25% OFF) *

ESA Plus - $141.75

Psychiatric Service Dog Letter for Travel

PSD Letter - $99.00