I have been under high levels of stress

I feel overwhelmed by my current life circumstances

I find myself depressed and/or saddened by my current life circumstances

I turn to Alcohol, Food, or drugs to comfort me in my current life circumstances

I am subject to outbursts, mood swings, or periods of negativity in my current life circumstances

Have you wished you were dead or have you felt that you or your family would be better off if you were dead?

Describe in detail how your pet helps you

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

In the past seven days (choose one):

In the past seven days (choose one):

In the past seven days (choose one):

In the past seven days (choose one):

In the past seven days (choose one):

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, how often have you avoided situations that make you anxious?

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

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

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)

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 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, how often have you felt down, depressed, or hopeless?

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

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?

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):

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

In the past seven days I had trouble sleeping.

In the past seven days my sleep was refreshing.

In the past seven days I had trouble staying asleep.

In the past seven days I got enough sleep.

In the past seven days my sleep was restless.

In the past seven days I was satisfied with my sleep.

In the past seven days I got enough sleep.

In the past seven days I had difficulty falling asleep.

In the past seven days my sleep quality was:

During the past two weeks how often did you use sedatives or tranquilizers (like sleeping pills or Valium) without a doctor's prescription, in greater amounts or longer than prescribed?

During the past two weeks how often did you use stimulants (like Ritalin, Adderall) without a doctor's prescription, in greater amounts or longer than prescribed?

During the past two weeks how often did you use Club drugs (like ecstasy)?

During the past two weeks how often did you use drugs like Marijuana?

During the past two weeks how often did you use drugs like Cocaine or crack?

Your new question!

During the past two week how often did you use Hallucinogens (like LSD)?

Have you ever received mental health treatment?

Have you ever been psychiatrically hospitalized?

Have you ever attempted suicide?

How does your pet help you feel better?

During the past two weeks how often did you use painkillers (like Vicodin) without a doctor's prescription, in greater amounts or longer than prescribed?

In the past seven days I was irritated more than people knew?

Over the past two (2) weeks, how often have you been feeling panic or being frightened?

In the past seven days how much have you been bothered by constipation, loose bowels, or diarrhea?

In the past seven days I felt angry.

In the past seven days I felt worthless.

During the past seven days, on average, how much time is occupied by these thoughts behaviors each day?

In the past seven days I felt like I was ready to explode.

In the past seven days how much have you been bothered by dizziness?

In the past seven days I felt that I had nothing to look forward to.

During the past seven days how much distress do these thoughts or behaviors cause you?

In the past seven days I felt fearful.

In the past seven days how much have you been bothered by fainting spells?

In the past seven days I felt helpless.

In the past seven days how hard is it for you to control these thoughts or behaviors?

In the past seven days I felt anxious.

In the past seven days how much have you been bothered by feeling tired or having low energy?

In the past seven days I felt sad.

In the past seven days I felt worried.

During the past seven days how much do these thought or behaviors cause you to avoid doing anything, going anyplace, or being with anyone?

In the past seven days I felt like a failure.

During the past seven days how much do these thoughts or behaviors interfere with school, work, or your social or family life?

In the past seven days I found it hard to focus on anything other than my anxiety.

In the past seven days I have felt depressed.

In the past seven days I felt nervous.

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

In the past seven days I felt hopeless.

In the past seven days I felt tense.

In the past seven days how much have you been bothered by pain in your arms, legs, or joints (knees, hips, etc.)?

In the past seven days how much have you been bothered by shortness of breath?

In the past seven days how much have you been bothered by trouble sleeping.

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

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

Did you know Federal law does not recognize "free ESA registrations" and that an airline or landlord may reject ESA cards and free ESA registrations?

Do you believe an ESA Letter could help you?

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

...choosing a state-licensed healthcare professional for your ESA Letter today?

Patient phone:

How soon are you looking to get your ESA letter?

Would you like a Care Specialists to call you and answer any remaining concerns you have?

How does your emotional support animal help alleviate the symptoms you are experiencing?

Have you or you currently taking medications for the symptoms listed above?

If so what types?

Have you ever been diagnosed with a mental health disorder?

Have you ever seen a therapist?

Have you ever seen a psychiatrist?

Have you ever been psychiatrically hospitalized?

How does your emotional support animal lessen your symptoms and improve your functioning?