Online Payment Form

Loading Form

Please Wait...

Personal Information

Client Name

Please enter your name.

Date of Birth *

Please enter your date of birth.

Date Completed *

Please enter the date completed.

Disability Determination

1. My emotional disability is evidenced by the following:

Depression

Anxiety

Trauma

Seizures

Nervousness

Any Other?

DO YOU HAVE DATA THAT SUPPORTS YOUR PSYCHOLOGICAL LIMITATIONS?

Yes

HAVE YOU HAD PSYCHOTHERAPY OR MENTAL HELP IN THE PAST?

Yes

HAVE YOU HAD A PSYCHOLOGICAL TEST?

Yes

DO YOU THINK YOU HAVE A MENTAL HEALTH ISSUES?

Yes

FUNCTIONAL IMPAIRMENTS ARE:

Stress

Sadness

Poor Appetite

Low Energy

Low Self Esteem

Anger

Unable to sleep or sleeps too much

Any Other?

DO YOU HAVE LIMITED ABILITY TO CONCENTRATE OR FOCUS ON ACTIVITIES OR TASKS?

Yes

DO YOU HAVE LIMITED EXPRESSIVE AND/OR RECEPTIVE COMMUNICATION?

Yes

DO YOU HAVE DIFFICULTY RELATING APPROPRIATELY WITH OTHERS?

Yes

DO YOU RESPOND INAPPROPRIATELY TO SOCIAL SITUATIONS?

Yes

DO YOU HAVE LIMITATIONS IN ORGANIZATION AND PLANNING?

Yes

DO YOU HAVE LIMITED OR NO ENERGY TO PERFORM ACTIVITIES?

Yes

DO YOU HAVE LIMITING STRESS, FRUSTRATION, OR ANGER TOLERANCE?

Yes

Other

Comments

2. Check if any of these impairments (listed above) impact one or more major life activities, such as: Other

Comments

Fair Housing Act

3. DOES YOUR EMOTIONAL SUPPORT ANIMAL PROVIDE EMOTIONAL SUPPORT AT HOME THAT ALLEVIATES ONE OR MORE OF YOUR IDENTIFIED SYMPTOMS?

Yes

Appropriateness/Efficacy of ESA, Informed Consent

4. I AM AWARE OF THE POTENTIAL RISKS AND BENEFITS ASSOCIATED WITH THE USE OF ESAS (CLINICAL AND ETHICAL/LEGAL) AND I AM MAKING A VOLUNTARY DECISION TO GET AN ESA LETTER.

Yes

5. I AM AWARE THAT THERE IS A PSYCHOTHERAPIST FOR TREATMENT IN THE OFFICE IN CASE I DECIDE TO GET TREATMENT.

Yes

6. I AFFIRM I HONESTLY NEED AN ESA LETTER TO BE PROVIDED TO ME

Yes

Client Information

Client Full Address

Please enter a valid email address.

Phone Number

Animal's Information

Animal Name

Animal Type/Breed

Animal Sex

Female

Male

Animal Date of Birth

Animal Age

Animal Weight (Pounds)

Animal Height (Inches)

Animal Length (Inches)

Animal Photo (accepted: .jpeg, .jpg, .png)

I hereby attest that I comply with all state, county and city/neighborhood rules, laws and regulations regarding my animal. My animal is registered and has an Animal License Tag from the local agency required where I live.

I confirm that this animal has been trained to behave appropriately in a public setting and takes my direction upon command.

I take full responsibility for the safety, well-being and conduct of this animal, including the animal's interactions with other animals and/or individuals.

Should this animal cause any loss, injury, damage or expense of any kind to another person, I consent and acknowledge that I accept liability for any such loss, injury, damage or expense.

Signature *

Sign above using your mouse or finger

Please sign the form.

Main Service

Consultation Fee

Optional Products

Add any of our products to your order. All products are optional — you may continue with only the professional consultation if you prefer.

Emotional Support Animal ID – $20.00

Service Dog ID – $20.00

ESA Medal – $12.00

Service Dog Medal – $12.00

ESA Vest – $25.00

Service Dog Vest – $25.00

Shipping Address (Optional)

Country/Region *

Please select your country/region.

State/Province *

Please enter your state/province.

Street Address *

Please enter your street address.

Town/City *

Please enter your town/city.

Zip Code *

Please enter your zip code.

Additional Information (optional)

I consent to the collection and processing of my personal information and, where applicable, health-related information, including any data I submit on behalf of others. This is for the purpose of evaluating or fulfilling my request, in accordance with the Privacy Policy.

Qualification Guarantee

If, after professional review and consultation, you are determined not to qualify, your consultation fee will be refunded 100%.

Payment is for the professional consultation/evaluation and does not guarantee approval or issuance of a letter.

I understand that I am paying for a professional consultation/evaluation and that a letter is not guaranteed. If the evaluating professional determines that I do not qualify, my consultation fee will be refunded 100%.

You must acknowledge the qualification guarantee before proceeding.

Card Number

Please enter your card number.

Name on Card

Please enter your name.

Expiry Date

Please enter your card expiry date.

Security Code

Please enter your card security code (CVV/CVC).