Name*

Date of Birth*

MM

DD

YYYY

Email*

Phone Number*

Gender:

Have you had any changes in your psychological and/or physical health in the past year?*

Please list the names of any prescription medications you have taken during the last 12 months or write NONE, if none.*

Have you experienced any major life events or traumatic events during the last 12 months?*

During the past 6 months have you been frequently worried about big and/or small life events?*

If you answered Yes, how frequently?

Do you have difficulties controlling your worries and anxiety?*

If you answered Yes, can you please describe what kind of events you worry about?

During the past 6 months have you been frequently sad, depressed for unknown reasons?*

If you answered Yes, how frequently?

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

Describe how you feel your Emotional Support Animal helps alleviate and/or relieves your mental/emotional symptoms.*

Please use this space to communicate anything else you would like your licensed mental health professional to be aware of.

Preferred Emotional Support Pet*

Number of animals*

Travel Plan*

Price: $149.00

Ad-ons

Total

$0.00

Shipping Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

*

*