Form

Form
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Preferred Contact Method
Reason for ESA/PSA Evaluation
Describe any mental health symptoms you are currently experiencing.
How long have you been experiencing these symptoms?
How do these symptoms affect your daily functioning?
Are you currently receiving mental health treatment?
List any diagnosed mental health conditions (if applicable)
Informed Consent

I understand that this evaluation is intended to determine whether I meet criteria for an Emotional Support Animal (ESA) or Psychiatric Service Animal (PSA) recommendation. I acknowledge that this assessment does not guarantee approval and that the clinician may request additional information if needed.
HIPPA Privacy Acknowledgment

HIPPA notice

I acknowledge that my personal and clinical information will be kept confidential in accordance with HIPAA regulations. My information will only be used for the purpose of this evaluation and will not be shared without my consent unless required by law.
Consent
Signature
Date Signed

MonthDayYear
Date