ESA Questionnaire

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Welcome to the first step of qualifying for an emotional support animal or psychiatric service dog! This simple questionnaire will just take a few minutes. We and the licensed professional you are paired with will keep your answers strictly confidential – they will never be shared with other third parties.

For your peace of mind, if you do not qualify for an ESA or PSD Letter, you will get a full refund in accordance with our 100% money back guarantee.

Please note that your information is saved on our server as you enter it.

First Name (Legal Name)*

Last Name*

Are you over 18 and acting on your own behalf?*

Are you over 18 and acting on your own behalf?

Date of Birth*

Month123456789101112

Day12345678910111213141516171819202122232425262728293031

Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Must be an adult 18+

Email*

Enter Email Confirm Email

Phone Number*

Gender*

Male

Female

Other

Preferred Emotional Support Pet*

e.g. dog, cat, dog and cat

Please note that per HUD guidelines the providers we work with can generally assist with dogs, cats, small birds, rabbits, hamsters, gerbils, other rodents, fish, turtles and other small, domesticated animals traditionally kept in the home for pleasure. We cannot assist with reptiles, barnyard animals, monkeys and other non-domesticated animals not considered common household animals.

Number of animals*

123

At this time, unfortunately, we are unable to assist you if you have more than 3 Emotional Support Animals.

Please send us a message via this form if you run into any issues or technical difficulties with submitting your order.

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Have you experienced any significant changes in your mood in the past 6 months?*

Yes

No

Please indicate if you have experienced any of the following symptoms in the past 6 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 have feelings of sadness or depression?*

Yes

No

On a typical day, how long do your feelings of sadness or depression persist?

Less than 1 hour

1-3 hours

3-5 hours

Greater than 5 hours

Do you have feelings of anxiety?*

Yes

No

On a typical day, how long do your feelings of anxiety persist?

Less than 1 hour

1-3 hours

3-5 hours

Greater than 5 hours

Does your anxiety, sadness or depression interfere with any of your major life activities?

Yes

No

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 describe what major life activities have been affected, and how.

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Have you experienced feelings of intense fear or helplessness after witnessing or experiencing a traumatic event?*

Yes

No

If yes, please indicate if you have experienced any of the following symptoms in the past 6 months.

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 90 days, how often have you been bothered by your emotions/symptoms from the traumatic event?

Rarely

Moderately

Often

Very Often

Other

Do the symptoms related to the traumatic event interfere with any major life activities?

Yes

No

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 describe what major life activities have been affected, and how.

Have you experienced a traumatic event that you would like to share with your licensed health professional?

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Have you experienced sudden and unexpected intense fear or anxiety for no apparent reason, or panic attacks, in the past six months?*

Yes

No

If you answered Yes, how often do these anxiety attacks occur?

Daily

Several times a week

A few times per month

Never

Other

Do you often worry that you will have panic attacks in the future?

Yes

No

During your last sudden and unexpected event of intense fear or anxiety, or panic attack, have you experienced any of the following?

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

Does your anxiety, worrying, panic attacks or fear of future panic attacks interfere with any of your major life activities?

Yes

No

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 describe what major life activities have been affected, and how.

In your experience, does having an animal present help alleviate/ameliorate symptoms of your mental and/or emotional health issues?*

Yes

No

If you answered YES above, please describe how your animal helps alleviate symptoms of your mental and/or emotional health issues.

If you have more than one animal you are seeking to qualify as an emotional support animal, please describe how each animal helps with your condition.

General Medical History: Please list and describe any illness (psychological or physical) you have been diagnosed with and any chronic medical conditions you have.*

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

Prescription Drug Use: Please list the frequency and dosage of any drugs (OTC, prescription) taken in the last 6 months.*

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.

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Is your ESA for On-Campus (Dorm) housing?*

Yes

No

If you are uncertain, please select “Yes” and we will follow up with you.

Notice Regarding On-Campus and University Housing – Please note that in our experience some universities can be challenging to deal with and vary widely in their policies. They can impose certain requirements and request additional documents. Most of our clients with valid ESAs are ultimately successful, but some are not. We offer support and extra document services if needed, but cannot process refunds if your university ultimately denies your request. Extra documents that are complex or require additional information are subject to review by your LMHP and may be subject to different fees – see our FAQ section for more details. Please confirm you would like to proceed with your order, or revise your order if you do not live in on-campus housing.*

I agree and would like to proceed

Select your plan

Choose the option that meets your needs! Our mission is to help you. If your Licensed Mental Health Professional (LMHP) determines you don’t qualify for an ESA letter, you’ll get 100% of your money back. Get the help you need.

Emotional Support Animal HousingESA Housing Letter

• Exemption from residential pet restrictions
• Signed ESA Letter on the provider’s letterhead
• Can be submitted to your landlord for ESA accommodation
• Digital Delivery
• PSD Add-on for $125
• Lock in yearly renewal rate of $125

• Mental health assessment
• Signed ESA Letter
• Discounted renewal rate: $125

$159

Select ESA Housing

Emotional Support Animal Housing PlusESA Plus

All benefits of Emotional Support Animal Housing plan, plus:

• Priority Support
• PSD Add-on for $99
• Lock in yearly renewal rate of $99

• All benefits of ESA Housing plan +
• Priority Support
• Discounted renewal rate: $99

$189

Select ESA Plus

Psychiatric Service DogPSD Travel Letter

• PSDs can board flights and are exempt from residential pet restrictions
• Signed PSD Letter on the provider’s letterhead
• States ADA eligibility
• Digital delivery
• Lock in yearly renewal rate of $125

• Mental health assessment
• PSD letter affirms ADA eligibility
• Lock in yearly renewal rate of $125

$199

Select PSD

Emotional Support Animal Plan*

ESA Housing – $159

ESA Plus – $189

The Combo Plan is our most popular plan because it is the only plan eligible for discounted renewal. The 2022 discounted renewal rate is only $99 while Housing or Travel only plans are billed at the full rate.

Notice Regarding Flights: As a result of rule changes by the U.S. Department of Transportation, many airlines are no longer accommodating emotional support animals. Some airlines will still welcome emotional support animals onboard. Please check with your airline directly prior to booking a flight to see what their latest policy is.

Opt-in for Discounted Annual Renewal

Annual Price Protection

Annual Price Protection — free (Recommended!)

• Grandfathers you into a discounted annual renewal fee ($125)
• No risk: complete your renewal next year or cancel auto-renewal if you no longer need it (no penalties)
• Eliminates administrative hassle next year, keeping you and your ESA protected.

• Grandfathers you into a discounted annual renewal fee ($99)
• No risk: complete your renewal next year or cancel auto-renewal if you no longer need it (no penalties)
• Eliminates administrative hassle next year, keeping you and your ESA protected.

You may also need

Expedited Service: Rush Digital Delivery

Expedited Service: Rush Digital Delivery — $49.50

• For time-sensitive orders – get your letter ASAP

Expedited Service orders are final and not refundable.

Psychiatric Service Dog Letter

Psychiatric Service Dog Letter — $125.00

• Establishes you have a qualifying condition under the ADA
• PSDs can board flights free of charge
• Purchase at a discount with your ESA plan

Psychiatric Service Dog Letter

Psychiatric Service Dog Letter — $99.00

• Establishes you have a qualifying condition under the ADA
• PSDs can board flights free of charge
• Purchase at a discount with your ESA plan

Are you considering training your dog to become a psychiatric service dog? A PSD letter can provide you with supporting documentation. A PSD must be individually trained to perform tasks relating to a mental health disability. Under recent U.S. air travel rules, ESAs are now limited on flights but PSDs can still board. A few things to note: A PSD letter does not in any way confirm, verify, certify or represent that you own or will own a service dog. Neither the healthcare professional you work with nor ESA Doctors is able make any representations or certifications about the qualification of your current or future animal as a service dog or its training or temperament. It is ultimately your responsibility to determine whether your canine meets service dog requirements and to make certifications to third-parties (including airlines).

Extra Documentation

Extra Documentation — $49.95

• Covers an extra administrative form or request your landlord may require.
• Extra document service is refundable if your landlord does not have extra administrative requests.

We recommend ordering the Extra Document service now to avoid any delays getting your ESA letter approved. 100% refundable if not utilized. Additional Extra Documentation can be added later at the same rate.

ESA Shield

ESA Shield — $75.00

Additional protection for a smooth ESA experience:

• Money-Back Guarantee
  If your landlord violates your rights or denies your ESA request, the cost of your ESA plan and add-ons, minus ESA Shield price, will be refunded.*
• Unlimited Priority Support
  Our top veteran ESA experts will have your back with unlimited, priority email support.

Restrictions and exclusions apply; read here for important details, and visit our FAQ to see if this add-on is right for you.

Custom ID Card – Partner Discount

Custom ID Card – Partner Discount (25% off) — now $33.00

• An optional accessory that ESA handlers find helpful. Orders through ServiceDogCertifications.org.

ID cards and registrations are not required by law and are for your convenience.

Hidden

Shipping Options*

Email Delivery OnlyEmail Delivery & USPS Priority Mail

Total:

Redemption Code

Please enter your code and click “Apply”

Credit Card*

Card Details

Cardholder Name

Place of Residence*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

How did you hear about us?*

OtherMy local shelterBingFacebookGoogleInstagramReferralTwitter

Let us know who to thank!

If other, please specify

Promotional Consent

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ESA Doctors and the licensed health professionals that work with us understand that you may be going through a difficult time, and we endeavor to treat everyone with compassion and respect. We also ask clients to be respectful towards their licensed health professionals and our support team. You hereby agree to the following: I understand that the licensed health professionals and customer service team are people just like me. I promise to abide by the golden rule and remain kind to everyone I speak with. If ESA Doctors or my licensed health professional determines that I have threatened anyone or acted inappropriately, I understand my order will be canceled. I understand that I should only submit an order if I am ready as ESA Doctors and the health professionals they work with have limited capacity. I have read the refund policy which will be strictly enforced if I need to cancel my order. Cancellations are subject to a fee and refunds will not be issued for landlord or airline denials, or changes in applicable laws or regulations. I have responded to the questionnaire truthfully and understand that my information may be shared with a licensed health professional and support staff.*

I have read and agree to the Terms and Conditions, Privacy Policy, and the following:

ESA Doctors and the licensed health professionals that work with us understand that you may be going through a difficult time, and we endeavor to treat everyone with compassion and respect. We also ask clients to be respectful towards their licensed health professionals and our support team. You hereby agree to the following: I understand that the licensed health professionals and customer service team are people just like me. I promise to abide by the golden rule and remain kind to everyone I speak with. If ESA Doctors or my licensed health professional determines that I have threatened anyone or acted inappropriately, I understand my order will be canceled. I understand that I should only submit an order if I am ready as ESA Doctors and the health professionals they work with have limited capacity. I have read the refund policy which will be strictly enforced if I need to cancel my order. Cancellations are subject to a fee and refunds will not be issued for landlord or airline denials, or changes in applicable laws or regulations. I have responded to the questionnaire truthfully and understand that my information may be shared with a licensed health professional and support staff.

Please send us a message via this form if you run into any issues or technical difficulties with submitting your order.

Comments

This field is for validation purposes and should be left unchanged.

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This form is not a diagnostic instrument and is solely used to inform the professional you are paired with to contact you. We may use your email address to contact you for transactional assistance – for example, if you do not properly complete the questionnaire or checkout process. The maker and provider of this form does not take responsibility for any liability, loss, or risk incurred as a consequence, directly or indirectly, from the use and application of any of this material. The actions of an emotional support animal is the full responsibility of its owner. By filling out this form and pressing next, you are providing your consent to ESADoctors.com to store and review your questionnaire for the purpose of connecting you with a licensed health professional so they can review your request. ESADoctors.com is not guaranteeing that a mental health professional will issue a recommendation for an ESA to you and will not influence the decision of the licensed mental health professional you are paired with. ESADoctors.com is not a medical clinic and we are not doctors, counselors, therapists, psychologists, lawyers, etc. ESADoctors.com is a technology company and does not make assessments, diagnosis, or provide any form of medical or mental health treatment or legal advice. Your privacy is important to us and we take it seriously. If you have any questions or concerns, contact us at support@esadoctors.com.