Emotional Support Animal (ESA) Letter Request Form

We’d love to get to know you:

Full Name

Date of Birth

Phone Number

Address

City

State

Zip Code

Now tell us about your beloved pet:

Pet's Name

Type of Pet

Cat

Dog

Other

if other, free text type of pet

Will you be using your health insurance, or paying out-of-pocket?

Paying out-of-pocket ($75 for one pet, $50 for each additional pet)

Front of CREDIT / DEBIT Card (YOU SHOULD SEE A PREVIEW OF THE PICTURE HERE)

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Back of CREDIT / DEBIT Card (YOU SHOULD SEE A PREVIEW OF THE PICTURE HERE)

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Front of GOVERNMENT ISSUED ID (YOU SHOULD SEE A PREVIEW OF THE PICTURE HERE)

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What mental health condition are you needing an emotional support animal letter for?

Please explain:

GAD-7 QUESTIONNAIRE

Instructions: CHECK the answer that best applies to you. Please answer each question as best you can.

	Not at all (0)	Several Days (1)	More than half the days (2)	Nearly everyday (3)
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritated
7. Feeling afraid as if something awful might happen

8. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

When did symptoms begin?

PHQ-9 QUESTIONNAIRE

Instructions: CHECK the answer that best applies to you. Please answer each question as best you can.

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

	Not at all (0)	Several Days (1)	More than half the days (2)	Nearly everyday (3)
1. Little interest or pleasure in doing things.
2. Feeling down, depressed, or hopeless.
3. Trouble falling or staying asleep, or sleeping too much.
4. Trouble relaxing
5. Poor appetite or over eating.
6. Feeling bad about yourself or that you are a failure or have let yourself or your family down.
7. Trouble concentrating on things, such as reading the newspaper or watching television.
8. Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual.
9. Thoughts that you would be better off dead, or of hurting yourself.

10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult