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Personal Information
Client Name
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Client Email
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Date of Birth
*
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Date Completed
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Disability Determination
1. My emotional disability is evidenced by the following:
Depression
Anxiety
Trauma
Epilepsy
Seizures
Nervousness
Other
Other
DO YOU HAVE DATA THAT SUPPORTS YOUR PSYCHOLOGICAL LIMITATIONS?
Yes
No
HAVE YOU HAD PSYCHOTHERAPY OR MENTAL HELP IN THE PAST?
Yes
No
HAVE YOU HAD A PSYCHOLOGICAL TEST?
Yes
No
DO YOU THINK YOU HAVE A MENTAL HEALTH ISSUES?
Yes
No
FUNCTIONAL IMPAIRMENTS ARE:
Stress
Sadness
Poor Appetite
Low Energy
Low Self Esteem
Anger
Unable to sleep or sleeps too much
Other
Comments
DO YOU HAVE LIMITED ABILITY TO CONCENTRATE OR FOCUS ON ACTIVITIES OR TASKS?
Yes
No
DO YOU HAVE LIMITED EXPRESSIVE AND/OR RECEPTIVE COMMUNICATION?
Yes
No
DO YOU HAVE DIFFICULTY RELATING APPROPRIATELY WITH OTHERS?
Yes
No
DO YOU RESPOND INAPPROPRIATELY TO SOCIAL SITUATIONS?
Yes
No
DO YOU HAVE LIMITATIONS IN ORGANIZATION AND PLANNING?
Yes
No
DO YOU HAVE LIMITED OR NO ENERGY TO PERFORM ACTIVITIES?
Yes
No
DO YOU HAVE LIMITING STRESS, FRUSTRATION, OR ANGER TOLERANCE?
Yes
No
Other
Comments
2. Check if any of these impairments (listed above) impact one or more major life activities, such as:
CARING FOR MYSELF
Yes
No
PERFORMING MANUAL TASKS
Yes
No
WALKING
Yes
No
HEARING
Yes
No
SPEAKING
Yes
No
BREATHING
Yes
No
LEARNING
Yes
No
WORKING
Yes
No
EMOTIONAL CONTROL
Yes
No
Other
Comments
Air Carrier and Access Act/14 CFR, Part 382
3. MY PET IS:
Service Dog
Animal Support
IS INDIVIDUALLY TRAINED OR ABLE TO PROVIDE ASSISTANCE TO ME?
Yes
No
IS THIS PET VERY NECESSARY FOR YOUR WELL BEING?
Yes
No
IS YOUR PET TRAINED TO BEHAVE APPROPRIATELY IN A PUBLIC SETTING?
Yes
No
4. I NEED THIS EMOTIONAL SUPPORT ANIMAL FOR:
Travel
Housing
Both
Fair Housing Act
5. DOES YOUR EMOTIONAL SUPPORT ANIMAL PROVIDES EMOTIONAL SUPPORT AT HOME THAT ALLEVIATES ONE OR MORE OF YOUR IDENTIFIED SYMPTOMS?
Yes
No
Appropriateness/Efficacy of ESA, Informed Consent
6. 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
No
7. I AM AWARE THAT THERE IS A PSYCHOTHERAPIST FOR TREATMENT IN THE OFFICE IN CASE I DECIDE TO GET AN APPOINTMENT.
Yes
No
8. I AFFIRM I HONESTLY NEED AN ESA LETTER TO BE PROVIDED TO ME
Yes
No
Client Information
Client Address
Client Phone Number
My Pet Information
Pet Name
Pet Type/Breed
Pet Weight in Pounds
Pet Tall (Inches)
Payment For
Select Payment
ESA 1 Letter (1 Assessment) [$99.00]
Other Payments
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Amount
$
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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
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Card Number
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Name on Card
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Expiry Date
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Security Code
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Total:
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