Emotional Support Animal Letter Questionnaire

Emotional Support Animal Letter

Questionnaire
Advanced Practice Headache and Primary Care Clinic

1128 Eagleridge Blvd. Pueblo, Colorado 81008 (719)778 -1414 theheadacheclinicco@gmail.com
Welcome to the first step of qualifying for an emotional support animal. This simple questionnaire will take just a few minutes.

A complete application for an Emotional Support Animal will take between 5 and 7 business days to process. Upon processing, the office will schedule an appointment once all paperwork and necessary forms are received.

In the event that you are not an established patient at APHPCC, medical records will be required to provide proof of the need for an ESA, along with a note stating your mental condition. Medical records not received within 5 business days of an ESA application could delay the approval process.

Please note that your information is saved on our server as you enter it.

DORA COLORADO Emotional Support Animal

Healthcare professionals must first establish whether a disability exists and if found, determine whether there is sufficient information for a recommednation for an ESA to provide a therapeutic benefit for that disability. In order to make such determinations, licensees must be both sufficiently familiar with the patient and the patient’s disability; and legally and professionally qualified to make this determination.

Nursing and mental health law (Section 12-255-133(3)(a) and 12-245-229(3)(a) Colorado Revised Statutes) further clarifies that “a licensee shall not make a determination … unless the licensee has met with the patient in person.” Registered nurses are permitted to issue ESA recommendations but must be under the direct supervision of a licensed physician.

Physicians shouldn’t make a determination unless having “met with the person or by telemedicine,” according to 12-240-144(3)(a), C.R.S

An ESA is an animal that provides a therapeutic benefit, such as emotional support, comfort, or companionship, to a person with a mental health or psychiatric disability. An ESA is not considered a Service Animal and ESA users don’t receive the same accommodations as service dog users.
ESAs Pricing

FOR ONE EMOTIONAL SUPPORT ANIMAL.
- Emotional Support Animal Letter $75The ESA letter is an official document 'prescribed' to the patient for mental/emotional disabilities to ensure their companion (pet) is protected under Federal Law (Fair Housing Act).
- Emotional Support Animal Certificate $ 15 This certificate is for secondary proof only and should be used in conjunction with a letter from a certified and licensed physician.
- Emotional Support Animal Badge $15 A badge for the ESA animal to wear. The badge will include the ESA certificate dates, expiration date, and the owner's contact information. The badge is another form of proof but should only be used with an ESA letter from a certified and licensed physician.
- Non-refundable administration fee ESA Letter fees include the $15 Administration Fee, which is not an additional charge. The $15 Fee Administration Fee will not be refunded if the patient does not qualify for the ESA Letter. . Therefore the refund amount would be $60.
Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Select one option below*

I confirm I am at least 18 years old and not acting on behalf of anyone else.I confirm that I am the parent or legal guardian of the minor above and will be acting on behalf of the patient.
Parent or Legal Guardian of Patient - If patient is a minor.

First NameLast Name
Place of Residence*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Confirm Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Gender*

MaleFemaleOther
APHPCC Refund Policy

APHPCC cannot guarantee that every landlord will follow the requirements outlined by the Federal Law under the Fair Housing Act (FHA), which protects a person with a disability that may have an emotional support animal. In the unlikely event, you are denied accommodation by a landlord or housing management agent due to a claim that your ESA Letter prescribed to you is not valid, we will provide you with the information resources to assist you.

We do offer a 100% money-back guarantee on our service if you are denied or do not qualify for an ESA Letter, except for the non-refundable $15 physician evaluation fee. Please email us at theheadacheclinicco@gmail.com or call us at 719-778-1414.
I agree and understand the APHPCC Refund Policy as stated above. *

Clear
Date*

MonthDayYear
Preferred Emotional Support Pet Name*
Emotional Support Animal Type/Breed (Example: Dog/ Labrador Retriever)*
Number of animals *
At this time, unfortunately, we are unable to assist you if you have more than 3 Emotional Support Animals.

In your experience, does having an animal present help alleviate/ ameliorate symtoms of your mental and/or emtional health issues?*

YesNo
If you answered Yes above, please describe how your animal helps alleviate symptoms of your mental and/or emotional health issues.*
Write "NONE" if you have not been diagnosed with any illness.
Prescription Drug Use: Please list the frequency and dosage of any drugs (Over the counter medications and Prescription drugs) taken in the last 6 months.*
Wite "NONE" if you have not consumed any OTC or Prescription drugs in the last year.
Is your ESA for on-campus (Dorm) housing?

YesNo

How did you hear about us?
The licensed health professional and staff with APHPCC understand that you may be going through a difficult time, and we endeavor to treat everyone with compassion and respect. We also ask clients to be respectful towards their licensed health professionals and staff. You hereby agree to the following: I understand that the licensed health professionals and staff are people just like me. I promise to abide by the golden rule and remain kind to everyone I speak with. If the licensed health professionals or staff determine that I have threatened anyone or acted inappropriately, I understand my ESA order will be canceled. I understand that I should only submit an order if I am ready, as licensed health professionals have limited time capacity. I have read the refund policy, which will be strictly enforced if I need to cancel my order. Cancellations are subject to a fee, and refunds will not be issued for landlord denials or changes in applicable laws or regulations. I have responded to the questionnaire truthfully and understand that my information may be shared with licensed health professionals and support staff.

It is necessary to schedule an appointment with our licensed professional before an Emotional Support Animal can be prescribed. (719) 778-1414
Signature*

Clear

ESAs Pricing
prevnext( X )
Emotional Support Animal LetterThe ESA letter is an official document 'prescribed' to the patient for mental/emotional disabilities to ensure their companion (pet) is protected under Federal Law (Fair Housing Act). ESA LETTER IS GOOD FOR ONE EMOTIONAL SUPPORT ANIMAL. ANOTHER LETTER MUST BE PURCHASED FOR EACH ADDITIONAL EMOTIONAL SUPPORT ANIMAL.
$75.00 Quantity



Emotional Support Animal CertificateThis Certificate is for secondary proof only and should be used in conjunction with a letter from a certified and licensed physician. ESA CERTIFICATE IS GOOD FOR ONE EMOTIONAL SUPPORT ANIMAL. ANOTHER LETTER MUST BE PURCHASED FOR EACH ADDITIONAL EMOTIONAL SUPPORT ANIMAL.
$15.00



Emotional Support Animal Bagde A badge for the ESA animal to wear comes in two colors red and blue. The badge will include the ESA certificate dates, expiration date, and the owner's contact information. The badge is another form of proof but should only be used with an ESA letter from a certified and licensed physician. ESA BADGE IS GOOD FOR ONE EMOTIONAL SUPPORT ANIMAL. ANOTHER LETTER MUST BE PURCHASED FOR EACH ADDITIONAL EMOTIONAL SUPPORT ANIMAL.
$15.00



Non-refundable Administration Fee MUST BE ADDED TO THE CART IN ORDER TO CHECK OUT! If patient does not qualify for the ESA Letter the $15 Fee Administration Fee will not be refunded. The $15 Administration Fee is a part of the ESA Letter.
$ Free



Total

$0.00

Payment Methods

Debit or Credit Card

First Name

Last Name

Credit Card Number

Security Code

Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

Emotional Support Animal Letter

Advanced Practice Headache and Primary Care Clinic