ESA Evaluation Screening Form 🧾
Complete this form to see if this service fits your needs and learn about the next steps.
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What state do you currently reside in?
*
Louisiana
Arizona
Other (not eligible)
Are you seeking an ESA letter for housing purposes?
*
Yes
No
Terms of Service:
Requires at least two sessions
May take approximately 2–4 weeks (Louisiana requires ~30 days)
Does NOT guarantee a letter
Is private pay only ($600- payment plans available)
You are responsible for the full package fee, even if you do not complete all sessions
Please confirm that you understand the terms of service
*
Yes
No
Are you willing to complete a clinical evaluation process rather than receive a same-day letter?
*
Yes
No
Briefly describe what you are hoping to receive from this service:
*
Submit Screening
Should be Empty: