DSM-V Level 1 Prequalify

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  • What type of pet do you have?

  • What is your pet’s name?

    Please fill in the field

    Next

  • Where are you most interested in taking your emotional support animal?

  • Have you ever been formally diagnosed with a mental health related condition by a medical professional? (Examples include: anxiety, depression, post traumatic stress disorder, insomnia, bipolar disorder, just to name a few)

  • Are you taking any medication now or have you taken any medication in the past for anxiety, ADHD or PTSD?

    Please select one answer

  • Has there been a major life event in the last year that has caused you great psychological stress? (Examples include: divorce, a breakup, financial troubles, unemployment, or a death in the family):

    Please select one answer

  • Over the past two (2) weeks, how often have you had little interest or pleasure in doing things?

  • Over the past two (2) weeks, how often have you felt down, depressed, or hopeless?

  • Over the past two (2) weeks, how often have you felt more angry, grouchy, or irritated than usual?

  • Over the past two (2) weeks, have you been sleeping less than usual, but still have a lot of energy?

  • Over the past two (2) weeks, have you been starting more projects than usual or doing more risky things than usual?

  • Over the past two (2) weeks, how often have you felt afraid or panicked?

  • Over the past two (2) weeks, how often have you felt worried, anxious, or on edge?

  • Over the past two (2) weeks, how often have you avoided situations that make you anxious?

  • Over the past two (2) weeks, have you experienced unexplained aches and pains (head, back, joints, abdomen, legs)?

  • Over the past two (2) weeks, have you been feeling that your illnesses are not being taken seriously enough?

  • Over the past two (2) weeks, have you had problems with sleep that affected your sleep quality overall?

  • Over the past two (2) weeks, have you unpleasant thoughts, urges, or images that repeatedly enter your mind?

  • Over the past two (2) weeks, have you felt driven to perform certain behaviors or mental acts over and over again?

  • Over the past two (2) weeks have you been drinking at least 4 drinks of any kind of alcohol in a single day?

  • Did you know there is no legal requirement to “register” your pet as an Emotional Support Animal (ESA)?

    Please select one answer

  • Did you know the only requirement under federal law for you to travel freely and obtain housing with your pet is an ESA Letter signed by a state-licensed health care professional?

    Please select one answer

  • Do you believe an ESA Letter could help you?

    Please select one answer

  • Where would you like us to email the results of this qualification survey?

    Please enter a valid email

    Next

  • What is most important to you in choosing a state-licensed healthcare professional for your ESA Letter today?

  • Client Gender:

  • Client First Name:

    Please fill in the field

    Next

  • Client Last Name:

    Please fill in the field

    Next

  • Client phone:

    Please enter a valid phone number

    Next

  • How soon are you looking to get your ESA Letter?

  • Do you have pet insurance?

    Please select one answer

  • Do you have health insurance?

    Please select one answer

  • Are you a student or do you have a membership in any of the following?

I hereby affirm everything is accurate and true to the best of my knowledge.

(You must answer all questions before submit)

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