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 just take a few minutes.

Please note that your information is saved on our server as you enter it.
ESAs Pricing
- Emotional Support Animal Letter $75 The 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 If the 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 fee.
Legal Name *

First Name Last Name
Date of Birth *

Month Day Year
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 Name Last Name
Place of Residence *

Street Address

Street Address Line 2

City State / Province

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

Male Female Other
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 *

Month Day Year
Preferred Emotional Support Pet and Name *
e.g. dog, cat, dog and cat
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? *

Yes No
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?

Yes No

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.
Signature *

Clear

ESAs Pricing
prev next ( X )
Emotional Support Animal Letter The 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).
$ 75.00 Quantity

Emotional Support Animal Certificate This Certificate is for secondary proof only and should be used in conjunction with a letter from a certified and licensed physician.
$ 15.00

Emotional Support Animal Bagde 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.
$ 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