ESA Evaluation
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Full Name
*
First Name
Last Name
Date of Birth
*
Ex: mm/dd/yyyy
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Administrative Sex
*
Please Select
Male
Female
Other
Gender Identity
*
Please Select
Female
Male
Trans Woman
Trans Man
Non-binary
Something else
Unknown
Choose not to disclose
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Service Preference
*
Please Select
In-Person (individual)
Telehealth (individual)
In-Person (couples or family)
Telehealth (couples or family)
Marital Status
*
Unmarried
Married
Domestic Partner
Divorced
Widow
Legally Separated
Interlocutory Decree
Annulled
Something Else
Choose Not To Disclose
Employment Status
*
Full-Time Employed
Part-Time Employed
Self-employed
Contract, per diem
Full-time Student
Part-time Student
On active military duty
Retired
Leave of absence
Temporarily unemployed
Unemployed
Something else
Group Therapy Preference (If Applicable)?
Please Select
Emotion Regulation Group
Veteran Support Group
What is your time preference? (Select all that apply)
*
Morning 8:00 AM - 12:00 PM
Afternoon 12:00 PM - 5:00 PM
Evening 5:00 PM - 8:00 PM
Fully Open Availability
What days of the week do you prefer? (Select all that apply)
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
I understand that the evaluation fee is non-refundable, regardless of whether I am deemed appropriate for an ESA recommendation. I agree to the total fee of $150 and acknowledge that this fee must be paid in full prior to the evaluation.
*
I agree
I would like more information
Type a question
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