• ESA Letter: Intake Questions

    Mindful Austin Therapy

  •  If you're a past client needing a renewal letter, click here

  •  ESA Appointments available:
    Sun - Thurs, 9am-11am

    *evening or Friday appointments available upon request for an additional charge of $25. Please email to inquire.

  • This form is confidential and HIPAA compliant
  • Format: (000) 000-0000.
  • Are you currently in therapy?*
  • If not, are you interested in learning more about, or pursuing therapy, at this time?

  • About Your Pet

  • Type of pet(s)*
  • Are you a student needing this letter for university housing?*
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  • General Questions

  • Have you experienced any significant changes in your mood in the past 6 months?
  • If yes, please select any symptoms you've experienced in the past 6 months
  • In the last 90 days, how often have you been bothered by your emotions/symptoms from your anxiety or mood changes?

  • Background Information

  • Which of these family dynamics did you experience? (please select all that apply)
  • Did you grow up in an environment that was unstable/difficult*, and/or do you feel that past events in your life have had a major and negative effect on your life today? (*Examples such as poverty, domestic violence, unreliable housing, family incarceration, lack of basic resources or healthcare, etc.)
  • Do you have a history of suicidal thoughts or attempts?*
  • Have you ever received more intensive mental health treatment, such as a hospital stay, partial hospitalization (PHP), or intensive outpatient program (IOP)?

  • Presenting Symptoms

  • Do you consider yourself to be a generally anxious person?
  • In the past 6 months, have you experienced a panic attack, or sudden, intense fears and anxiety that seemed to come out of nowhere?
  • If yes, how often do these panic attacks occur?
  • Do you often worry that you will have panic attacks in the future?
  • During your last panic attack, have you experienced any of the following symptoms?
  • Does your worrying (general anxiety), 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.

  • Do you have feelings of sadness or depression?
  • Do your feelings of sadness or depression interfere with any of your major life activities?*
  • Have you witnessed or experienced a traumatic event?
  • If yes, have you experienced any of the following symptoms in the past 6 months?
  • In the past 90 days, how often have you been bothered by these symptoms?
  • Do the unwanted thoughts or feelings related to the traumatic event interfere with any of your major life activities?

  • Next Steps 

    In order for me to evaluate if you meet the qualifications for an ESA Letter, we must arrange a 30 minute meeting by phone ($130)
    Insurance is not accepted for ESA appointments


    If you'd like to move forward with this process, please continue to the next page where you will review and sign the Informed Consent and then be directed to the online scheduling page.

     

  • Informed Consent

    Please read the following information, which outlines the nature of our work together. Your signature at the bottom of this form acknowledges that you have reviewed and agreed to these terms.

  • Confidentiality
    Texas state law requires that information provided to licensed professional counselors remain confidential. However, there are occasions in which confidentiality may be broken and case information must be disclosed to appropriate authorities, agencies, or individuals:
    • If I have reason to believe that you may harm yourself or others.
    • If I have reason to believe that you are involved in or have knowledge of abuse or neglect of a child, elderly person, or disabled person.
    • If I am ordered by a court to disclose information regarding our counseling.
    • If you’d like me to consult with other health care professionals or family members regarding our work together, please request a Release of Information Form from me.


    ESA Letter Service Information
    The service I'm providing is to assess if there is a psychological need for an Emotional Support Animal based on your symptoms meeting the criteria for a mental health disability, as classified within the DSM-V. Your appointment and payment is for my assessment services and does not guarantee a certification letter, as that can only be granted if I see evidence that warrants a diagnosis. 

    Emotional support animals are recognized by the ADA as a companion animal that provides necessary support for a person struggling with a mental health disorder, as confirmed by a licensed mental health professional. Because they are not service animals, they do not require specialized training. However, it is the responsibility of you, the pet owner, to ensure your pet is well-behaved enough to not pose a safety threat or be disruptive in the places you bring it to. In the event that your pet bites or harms someone, the liability rests solely on you. As a therapist writing an ESA Letter, I can only attest to your NEED for an emotional support animal and in no way can assess the behavior and safety of your pet. 

    An Emotional Support Animal Letter grants you the right to live with your animal without being subject to landlord pet policies (ex: deposits, pet rent, breed or weight restrictions). This is the only place an ESA Letter provides qualification for. Your letter does not qualify you to bring your pet with you to stores, hotels, or any other place of business that has their own pet restriction policies. Most airlines no longer allow ESAs on board. If this is something you are needing, please reach out to the specific airline to understand their policies.

    If you qualify to receive an ESA Letter, it is only valid for 1 year. If you need your letter renewed after that time, you're required to have an assessment done again to ensure you still meet the qualifications.


    Fees & Policies
    Insurance is not accepted for this service
    Phone: $130  

    ASAP Delivery: $35
    If you qualify for an ESA Letter and need it same day, it will incur this fee. The typical turnaround time for your letter is between 3 and 5 days.

    Payment is required at the time you schedule your appointment (which will be through the online calendar you'll be sent to after completing this form).

    Your letter will be emailed to you as a PDF. If you need additional forms completed that are specific to your leasing property (or school housing), please email those to me before your appointment.

    In the event that you are not able to keep your appointment, please cancel at least 24 hours in advance in order to receive a refund. 


    Therapeutic Relationship
    Our relationship is strictly professional and contained to mental health services only. No personal relationships are permitted during or after our work together. 

    In the event you are dissatisfied with my services, please let me know. This gives us an opportunity to address your dissatisfaction and, hopefully, eliminate it. If you remain dissatisfied and would like to file a complaint with the Texas State Board of Examiners of Professional Counselors, you may call them at 1- 800-942-5540 or mail them at: Complaints Management and Investigative Section, P.O. Box 141369, Austin, Texas 78714.


    Crisis
    If you are in a crisis situation, please contact Austin Travis County Integral Care crisis line at 512-472- 4357. In cases of emergency please dial 911.

    • Demographic Information * 
    • Demographic Info 
    • Signature * 
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