Form

Form
IMPORTANT NOTICE
Before completing this form or submitting payment, please review our Refund Policy, Terms of Service, No‑Guarantee of Outcome Statement, and FHA Disclaimer on our website.
By continuing, you acknowledge and agree to these policies.
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
2 digit month, 2 digit day, 4 digit yearDate
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 for ESA/PSA Clinical Evaluation
I understand that this evaluation is a clinical assessment intended to determine whether I meet criteria for an Emotional Support Animal (ESA) or Psychiatric Service Animal (PSA). I acknowledge that:

This assessment does not guarantee approval.
The clinician may request additional information if needed.
ESA/PSA documentation is issued only when clinically appropriate and medically necessary.
Housing providers make independent decisions under the Fair Housing Act (FHA).
Clinical services are non‑refundable once delivered, including intake review and assessment.
I acknowledge that clinical services are non‑refundable once delivered, including intake review and assessment.Type a question
I understand that ESA/PSA documentation does not guarantee housing approval and that housing providers make independent decisions under the FHA.
TI agree not to file chargebacks for outcomes outside the clinician’s control, including housing provider denial, delays, or non‑response.
I understand that Care Haven Pets LLC is responsible for clinical assessment only, and that FHA enforcement is handled through HUD or Fair Housing agencies.
HIPAA Privacy Acknowledgment
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
2 digit month, 2 digit day, 4 digit yearDate

My Services

Debit or Credit Card
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty: