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Personal Information

Pet
Details

Questionnaire

We’re Almost Ready—Tell Us About You

Please enter your name

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Let’s Start by Finding Your State!

When’s Your Birthday?

* To qualify for an ESA letter you must be 18 years or older

What Gender Do You Identify As?

Male
Female
Other

Select the Type of Your Pet Companion

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Dog

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Cat

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Other

Help Us Get to Know More About Your Pet

What Do You Call Your Beloved Companion?

Over the past two weeks, how often have you had little interest or pleasure in doing things that you usually like to do?

Never
Rarely
Sometimes
Often
Always

Over the past two weeks, how often have you felt sad or depressed?

Never
Rarely
Sometimes
Often
Always

Over the past two weeks, how often have you felt more angry or more irritated than usual?

Never
Rarely
Sometimes
Often
Always

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

Never
Rarely
Sometimes
Often
Always

Over the past two weeks, how often have you felt afraid or panicked?

Never
Rarely
Sometimes
Often
Always

Over the past two weeks, how often have you had irregular sleep? (Sleeping too much or too little)

Never
Rarely
Sometimes
Often
Always

Over the past two weeks, how often have you been acting impulsively? (Shopping too much, sudden use of drugs or alcohol, feeling like you’re “on top of the world”)

Never
Rarely
Sometimes
Often
Always

Over the past two weeks, how often have you avoided situations that make you nervous?

Never
Rarely
Sometimes
Often
Always

Over the past two weeks, how often have you heard things other people couldn’t hear and seen things other people couldn’t see?

Never
Rarely
Sometimes
Often
Always

Over the past two weeks, how often have you felt paranoid or    fearful you are in danger?

Never
Rarely
Sometimes
Often
Always

Over the past two weeks, have you had thoughts of suicide?

YES
NO

Note: (If Yes then the person is disqualified and ESA letter can’t be prescribed) The person should seek help elsewhere.

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Do you want to add another pet for $49.00?

Yes
No, thanks
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That’s it! Now simply confirm your information as correct.

Enter your name in the signature box below to verify the accuracy of your answers to the best of your knowledge.

I, Myles, hereby certify that the information I have submitted to RealESAletter.com is truthful and accurate to the best of my knowledge.

My signature below confirms my understanding that my information will be digitally and securely forward to a licensed mental health professional who will assess my suitability for an Emotional Support Animal. I further agree that my responses here may be viewed by a therapist and the administrative professionals at RealESAletter.com for the purpose of issuing my ESA Letter.

I hereby agree to all RealESAletter.com terms and conditions and give my permission for their personnel to convey my information to a licensed therapist who may prescribe treatment of any issues appropriate to the issuance of my ESA letter.

I understand that if I am experiencing a medical or emotional emergency, I am to seek treatment from the appropriate professionals at the nearest emergency medical facility.

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