REQUEST FOR E.S.A. LETTER

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Do you currently have an emotional support animal?*

YesNo

Name of pet

Breed

(dog, cat, lizard etc)

Gender of pet*

MaleFemale

Is your pet neutered or spayed?*

YesNoI plan to neuter/spay my pet

Does your pet have any health or behavioral problems?*

YesNo

Please explain:

Has your pet been temperament tested?*

YesNo

Has your pet received a "Good Citizenship" certificate?*

YesNo

Name of certifying agency

I am aware that E.S.A. letters must be renewed annually?*

Yes

What are your reasons for requesting an ESA letter?*

Tell me a little bit about your Emotional Support Animal. What is their personality and temperament like? How do they help you emotionally?*

ESA Prescription Letter Requirement

1. You will need to be actively enrolled in therapy with me for a minimum of 6 sessions.

2. You need to have a current mental health diagnosis.

3. You must currently have the pet in your posession.

4. You must be the owner of the pet.

5. I need to be able to see you interact with your pet (in person or on line).

6. You will need to explain:

A. How your pet helps to alleviete your symptoms.

B. How your pet helps you function more effectively at home, school, work, socially, completing everyday tasks, etc.

7. An ESA letter can be revoked or not renewed at any time if a client does not continue to qualify for the prescription.

I understand the policies for qualifying for an ESA prescription letter.*

I hold this mental health practitioner harmless for any behavioral issues that may arise with my pet.*