ESA Renewal

ESA Renewal

Mindful Austin Therapy
In order to receive an ESA renewal letter, I have to see that you are still experiencing symptoms that meet critiera for a disorder and that having your pet helps alleviate those symptoms. Please complete the rest of this form to help me assess if you still meet the criteria.
Name*

First NameLast Name
Email*
example@example.com
Are you still a Texas resident? (I'm only able to provide this service to Texas residents)*

YesNo
Gender Pronoun*
About Your Pet
Type of pet*

Dog(s)Cat(s)OtherCombination of pet types
Name of your pet(s)*
If you selected multiple pets, be sure to say which name goes with which type of animal
Breed(s)*
Age(s)*
Weight(s)*
Mental Health Questions
Please select the symptoms that you frequently experience (within the past 6 months) that have caused distress:*

Increased anxietyPanic attacksDifficulty with focus and concentrationConstant worry or worst-case-scenario thinkingIrritability, agitation, or angerFatigueRestlessnessChanges in your sleep or ongoing sleep issuesMuscle tensionDepressed moodElated moodDecreased interest in activities you once enjoyedLack of motivationChanges in your weightChanges in your appetiteFeelings of worthlessness or hopelessnessIndecisivenessThoughts of wanting to hurt yourself or othersDifficulties with daily living activities (ex: meal prep, paying bills, housekeeping, personal hygiene)Missing work or school, or performing poorly at work or schoolIsolation or changes in your social functioning (not spending as much time with friends or family)Have had a recent traumatic event, or are experiencing PTSD symptoms from a traumatic event in your pastOther
Are you currently seeing a therapist? If yes, for how long?*
Please describe which symptoms your pet most helps with right now + how they help with those symptoms:*
Is there anything else you'd like to share that will help me better assess your continued need for your ESA?
Next Steps
After you submit this form and payment, you'll receive an email with your new letter within 2-4 days if I see that you still meet critieria. If not, I'll reach out to you with more questions first. In the event that you do not meet criteria for the letter, your payment will be refunded.

Payment

ESA Renewal Letter

$65

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

ESA Renewal

About Your Pet

Mental Health Questions

Next Steps