ESA Evaluation Query Form

1

Start Your ESA Evaluation

How it works:

Complete a brief 2-minute background questionnaire for your appointment.
Attend a thorough clinical evaluation with a licensed Texas mental-health professional.
If clinically appropriate, receive your ESA documentation, typically within 24 hours of your appointment.

Our ESA documentation is prepared to support reasonable accommodation requests under the Fair Housing Act (FHA), when clinically appropriate.

2

Are you physically located in the State of Texas?* This field is required.

YESNO

3

Name* This field is required.

First Name

Last Name

4

Name Check

5

Calculation

6

Are you 18 or older?* This field is required.Note: if under 18, a parent will need to sign an online consent form prior to the evaluation

YESNO

7

Birthdate* This field is required.

Date

8

E-mail* This field is required.

example@example.com

9

Phone Number* This field is required.

10

What type of accommodation are you requesting documentation for?* This field is required.Select all that apply

Apartment Housing

Rental Home

College Domitory

Other

11

ESA Detail Information* This field is required.Enter details for each ESA; select how each helps you (Helps Me By should be different for each one). Note that the therapist will be conducting a thorough evaluation to determine whether you truly qualify for each ESA.

12

Are you available now for a clinical consultation to see if you qualify? Note: we can talk to you between 8am-8pm.* This field is required.

YESNO

13

Can you give us a date and time you are available for a clinical assessment?* This field is required.

14

Have you ever been diagnosed with Anxiety?* This field is required.

YESNO

15

Have you ever been diagnosed with Depression?* This field is required.

YESNO