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  • Psychological Evaluation

  • The following exam consists of seven parts with 73 total questions that should take approximately 30-45 minutes to complete. Each question MUST be answered (unless indicated as optional).

    There is no time limit so PLEASE TAKE YOUR TIME and provide complete answers to all questions. Evaluations lacking sufficient information will be rejected.

    If a question does not apply to you please answer "No" or "None" in the appropriate field. If a required question is left blank you will not be able to submit the exam.

    When finished please click the "checkout" tab which will save your exam on our server and lead you to a Payment review page. Once payment is completed please allow 2-3 business days for your test results and prescription if a diagnosis can be made.


    Please note the airline rules have changed and air carriers will not accept ESA's for reservations made after March 1st 2021. Housing prescriptions will continue to be protected under the Fair Housing Act.

  • Part I. Personal Information
  •  -
  • Gender:*
  • Preferred Emotional Support Pet (One Emotional Support Pet per person). If you desire more than one pet please contact us first.*

  • Pet Breed Approximate Pet Weight LBS

  • Has your pet ever bitten anyone or exhibited aggressive behavior.*

  • Prescription Options

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                • Please provide as much information as possible so we are not delayed if we need to ask for more information later.
                • Part II. General Mental and Physical Health
                • Question 3. Impact on Major Life Activities: Is there one or more major life activity that you are unable to perform (or have great difficulty performing) because of problems caused by stress or any other emotional problem? (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).*

                • Drug and Alcohol Use: Similar to Major Life Events sometimes symptoms of psychological problems can be caused by Illegal Drug use or excessive alcohol consumption. To better understand your current mental health condition please provide the following information.

                • Part III PTSD - Please write complete answers when requested and type Yes or No to all questions or write "Unsure" if you do not know.

                • Question 9. Have you ever been exposed to a traumatic event in which your life or someone else"s was actually in danger or you thought your life or someone else"s was in danger?*
                • Question 10. Did you experience feelings of intense fear or helplessness after the event?*
                • Question 11. Have you had recurrent unwanted recollections of the traumatic in last 6 months - including thoughts, dreams or perceptions?*
                • Question 12. Have you ever had flashbacks or feelings you were reliving the traumatic event even while you"re awake?*
                • Question 13. Do you have intense feelings of distress or anxiety when reminded of the traumatic event?*
                • Question 14. Do you try to avoid people or places that remind you of the traumatic event?*
                • Question 15. Do you try to avoid conversations or thoughts that remind you of the traumatic event?*
                • Question 16. Since the traumatic event have you been much more alert or looking out for possible trouble? *
                • Question 17. Since the traumatic event took place have you had difficulty concentrating?*
                • Question 18. Since the traumatic event have you felt irritable or had outbursts that you had difficulty controlling?*
                • Question 19. Since the traumatic event took place do you have difficulty sleeping?*
                • Question 20. Since the traumatic event took place are you less interested in activities you previously enjoyed?*
                • Question 21. Since the traumatic event took place have you had difficulty meeting new people?*
                • Question 22. Do reminders of the traumatic event cause physical symptoms of distress, such as trembling, shortness of breath, increased pulse, muscle aches, or sweating?*
                • Question 23. Do you feel your future life may be negatively impacted as a result of the traumatic event?*
                • Question 24. Since the traumatic event took place have you had difficulties showing emotions of love or affection?*
                • Question 25. In the last 90 days how often have you been bothered by your emotions/symptoms from the traumatic event (rarely, Moderately, Often, Very Often, or None of the Above)*

                • Question 26. Do the unwanted thoughts or feelings related to the traumatic interfere with any major life activity (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.)*
                • Part IV GAD Please write complete answers when requested and type Yes or No to all questions or write "Unsure" if you do not know.
                   
                • QUESTION 27. During the past six months have you been frequently worried about big or small events in your life?*
                • If you answered Yes above, how frequently has your worrying caused anxiety or stress in the last six months on a daily basis(more frequently), several times each week(frequently), only a few times each month or less, or None)

                • QUESTION 29. Do people ever say you worry about things too much?*
                • QUESTION 30. Do you think you worry about things too much?*
                • QUESTION 31. Do you have difficulty controlling your worries or anxiety?*
                • QUESTION 32. How long have you had difficulty controlling your worries in the past 12 months?*

                • QUESTION 33. When worried do you frequently feel irritable or on edge for no apparent reason?*
                • QUESTION 34. Do you often worry something bad is going to happen to you or someone close to you?*
                • QUESTION 35. When worried do you have frequently have difficulty sleeping?*
                • QUESTION 36. When worried do you have tensions or muscle aches?*
                • QUESTION 37. Do you often become tired easily or experience a sudden unexplained loss of energy?*
                • QUESTION 38. Does your worrying interfere with any major life activity? (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.)*
                • Part V. PD Please write complete answers when requested and type Yes or No to all questions or write "Unsure" if you do not know. 
                • QUESTION 39. Have you ever experienced sudden and unexpected intense fear or anxiety for no apparent reason (panic attack) or in situations where you did not expect it to occur in the past 6 months?*
                • QUESTION 40. If you answered yes to #39 how often do these anxiety attacks occur - on a daily basis (more frequently), several times each week (frequently), only a few times each month, or None

                • QUESTION 42. Do you often worry that these panic attacks will have negative health consequences - possible heart attack, losing control, or other debilitating affects?*
                • QUESTION 43. Do you often worry that you will experience more panic attacks in the future?*
                • QUESTION 44. During your last panic attack did you feel your pulse increase (increased heart rate)?*
                • QUESTION 45. During your last panic attack did you experience uncontrollable shaking or trembling?*
                • QUESTION 46. During a panic attack did you often feel dizzy or nauseous?*
                • QUESTION 47. During your last panic attack did you have difficulty breathing or feel like you were out of breath?*
                • QUESTION 48. During your last panic attack did you have hot flashes or experience profuse sweating?*
                • QUESTION 49. During your last panic attack did any of your extremities (legs, fingers, toes, ect.) feel numb?*
                • QUESTION 50. During your last panic attack did you feel detached from reality, almost like you were dreaming?*
                • QUESTION 51. Do your panic attacks or fear of future panic attacks interfere with any of your major life activities? 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.*
                • Part VI SSP Please write complete answers when requested and type Yes or No to all questions or write "Unsure" if you do not know. 
                • QUESTION 52. Do you have an intense fear that you will do or say something in front of others that will embarrass you? *
                • QUESTION 54. Does your fear in question #53 cause you intense stress or anxiety?*
                • QUESTION 55. Before, during or immediately after the feared activity in question #53 do you experience any physical symptoms such as shaking, trembling, perspiring or nausea?*
                • QUESTION 56. Have you ever completely avoided the activity in Question #53 because of fear or anxiety?*
                • QUESTION 57. Does your fear prevent you from performing said activity in Question #53 or make the task extremely difficult completing?*
                • QUESTION 58. Do you think you are more afraid or worried than you should be?*
                • QUESTION 59. Does the feared activity in question #53 interfere with any of your major life activities? 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.*
                • Part VII. MD Please write complete answers when requested and type Yes or No to all questions or write "Unsure" if you do not know. 
                • QUESTION 60. Do you often feel sad or depressed for unknown reasons? *
                • QUESTION 61. If you answered yes to #60 how often have you felt sad or depressed in the last 30 days? On a daily basis (more frequently), several times each week (frequently), only a few times each month, or None*

                • QUESTION 62. On a typical day how long do your feelings of sadness or depression persist?*

                • QUESTION 63. Has your depression or feelings of sadness caused significant changes in appetite, causing you to eat significantly more or less?*
                • QUESTION 64. If you answered YES above, in the last 3 months how long has your appetite been increased or decreased ? Very Mild (one week or less); Mild (one week to two weeks), Moderate to Severe (two weeks to one month) Severe (more than one month) or None of the above.*

                • QUESTION 65. Has your depression caused you to gain or lose a significant amount of weight (greater than 5%) in any given month?*
                • QUESTION 66. Have you lost interest in activities you previously enjoyed because of feelings of sadness or depression?*
                • QUESTION 67. If you answered YES above, in the last 3 months how long has your disinterest in previously interested activities persisted for? Short term (one week or less); Mild (one week to two weeks), Moderate (two weeks to one month) Severe (more than one month) or None of the above.

                • QUESTION 68. Do you often have feelings of worthlessness or often experience low self esteem*
                • QUESTION 69. If you answered YES above, in the last 3 months how often have you experienced feelings of worthlessness or low self-esteem? Short term (one week or less); Mild (one week to two weeks), Moderate (two weeks to one month) Severe (more than one month) or None of the above.

                • QUESTION 70. Do you have difficulty sleeping or sleep too much? If so, in the last 3 months how often do you experience difficulty sleeping? On a daily basis (more frequently), several times each week (frequently), only a few times each month, or None*

                • QUESTION 71. Do you often feel fidgety or have problems sitting still?*
                • QUESTION 72. Do you often feel fatigued or suffer from an unusual loss of energy? If so how often do you experience fatigue?*

                • QUESTION 73. Do the unwanted feelings of sadness or depression interfere with any major life activity (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.)*

                • Congratulations - You're Finished!! Please click "Proceed to Checkout" Below to Submit and Save Your Exam and then Complete Payment.

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