1. Are you unable to meet with a licensed mental health professional in person today for your ESA evaluation?
2. We offer a wide range of state-licensed health care professionals to certify your emotional support animal letter. Please choose your preference (subject to availability):
3. What type of pet do you have?
4. What is your pet’s name?
5. Where are you most interested in taking your emotional support animal?
6. Do you have health insurance?
7. Have you ever been formally diagnosed with a mental health related condition by a medical professional? (Examples include: anxiety, depression, post traumatic stress disorder, insomnia, bipolar disorder, just to name a few)
8. What was the diagnosis?
9. Are you taking any medication now or have you taken any medication in the past for anxiety, ADHD or PTSD?
10. Has there been a major life event in the last year that has caused you great psychological stress? (Examples include: divorce, a breakup, financial troubles, unemployment, or a death in the family):
11. Over the past two (2) weeks, how often have you had little interest or pleasure in doing things?
12. Over the past two (2) weeks, how often have you felt down, depressed, or hopeless?
13. Over the past two (2) weeks, how often have you felt more angry, grouchy, or irritated than usual?
14. Over the past two (2) weeks, have you been sleeping less than usual, but still have a lot of energy?
15. Over the past two (2) weeks, have you been starting more projects than usual or doing more risky things than usual?
16. Over the past two (2) weeks, how often have you felt afraid or panicked?
17. Over the past two (2) weeks, how often have you felt worried, anxious, or on edge?
18. Over the past two (2) weeks, how often have you avoided situations that make you anxious?
19. Over the past two (2) weeks, have you experienced unexplained aches and pains (head, back, joints, abdomen, legs)?
20. Over the past two (2) weeks, have you been feeling that your illnesses are not being taken seriously enough?
21. Over the past two (2) weeks, have you had problems with sleep that affected your sleep quality overall?
22. Over the past two (2) weeks, have you unpleasant thoughts, urges, or images that repeatedly enter your mind?
23. Over the past two (2) weeks, have you felt driven to perform certain behaviors or mental acts over and over again?
24. Over the past two (2) weeks have you been drinking at least 4 drinks of any kind of alcohol in a single day?
25. Over the past two (2) weeks have you smoked any cigarettes, a cigar, or pipe, or used snuff or chewing tobacco?
26. Over the past two (2) weeks have you been using any of the following medicines without a doctor’s prescription, in greater amounts or longer than prescribed e.g., painkillers like Vicodin, stimulants like Ritalin or Adderall, sedatives or tranquilizers like sleeping pills or Valium, or drugs like marijuana, cocaine or crack, club drugs, hallucinogens, heroin, inhalants or solvents, or methamphetamine?
27. Did you know there is no legal requirement to “register” your pet as an Emotional Support Animal (ESA)?
28. Did you know Federal law does not recognize "free ESA registrations” and that an airline or landlord may reject ESA cards and free ESA registrations?
29. Did you know the only requirement under federal law for you to travel freely and obtain housing with your pet is an ESA Letter signed by a state-licensed health care professional?
30. Do you believe an ESA Letter could help you?
31. Where would you like us to email the results of this qualification survey?
32. What is most important to you in choosing a state-licensed healthcare professional for your ESA Letter today?
33. Patient First Name:
34. Patient Last Name:
35. Patient phone:
36. How soon are you looking to get your ESA Letter?
37. Are you a student or do you have a membership in any of the following?
38. Would you like a Care Specialist to call you and answer any remaining concerns you have?
I hereby affirm everything is accurate and true to the best of my knowledge.
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