This form is not a diagnostic instrument and is solely used to inform the professional you are paired with to contact you. 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 firstname.lastname@example.org.