American Service Animals - ESA Application Form

Step 1: Application Form Step 2: Consent Form Step 3: Confirmation

ESA Letter Application

Complete your Emotional Support Animal evaluation - secure and confidential

Personal Information

Tell us about yourself for your ESA letter

First Name

Last Name

Email Address

Phone Number

Create Password *

Confirm Password *

Full Name

Letter Type

Preferred Contact Method

Preferred Contact Time

Pet Information

Tell us about your emotional support animal(s)

Primary Pet (Required)

Primary Pet Name

Pet Type

Pet Weight (lbs)

Pet Breed

Pet Sex

Pet Photo

Second Pet (Optional)

Pet Name (2)

Pet Type (2)

Pet Weight (lbs) (2)

Pet Breed (2)

Pet Sex (2)

Pet Photo (2)

Third Pet (Optional)

Pet Name (3)

Pet Type (3)

Pet Weight (lbs) (3)

Pet Breed (3)

Pet Sex (3)

Pet Photo (3)

Mental Health Assessment

Standardized questionnaires to evaluate your mental health needs

PHQ-9 Depression Assessment

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself or that you are a failure

Trouble concentrating on things like reading or watching TV

Moving or speaking slowly, or being fidgety/restless

Thoughts that you would be better off dead or hurting yourself

GAD-7 Anxiety Assessment

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Feeling nervous, anxious, or on edge

Not being able to stop or control worrying

Worrying too much about different things

Trouble relaxing

Being so restless that it is hard to sit still

Becoming easily annoyed or irritable

Feeling afraid as if something awful might happen

Ready to Submit?

Review your information and proceed to the consent form

Your information is encrypted and HIPAA compliant