Intake Form Get In Touch schedule a consultation Date *Name and Breed Of Pet *Full Name *Date Of Birth *Phone Number *Email Address *Street Address *Where did you hear from us?Which type of letter are you seeking today? *Psychiatric Service Dog (PSD) LetterEmotional Support Animal (ESA) LetterHave you ever been diagnosed with a mental health condition? If Yes, please describeCurrent symptoms *AnxietyDepressionPTSDPanic AttacksInsomniaOtherWrite HereCurrent treatment *TherapyMedicationsNoneOtherWrite HereHow do your symptoms affect daily life? *WorkSchoolHousingSocialSleepPanic attacksOtherWrite HereHow do you believe ESA/PSD would help you? *PHQ-9 Depression Screening 0 – Not at all 1 – Several days 2 – More than half the days 3 – Nearly every day Little interest or pleasure in doing things *Not at allSeveral daysMore than half the daysNearly every dayFeeling down, depressed, or hopeless *Not at allSeveral daysMore than half the daysNearly every dayTrouble falling or staying asleep, or sleeping too much *Not at allSeveral daysMore than half the daysNearly every dayFeeling tired or having little energy *Not at allSeveral daysMore than half the daysNearly every dayPoor appetite or overeating *Not at allSeveral daysMore than half the daysNearly every dayFeeling bad about yourself, or that you are a failure *Not at allSeveral daysMore than half the daysNearly every dayTrouble concentrating on things *Not at allSeveral daysMore than half the daysNearly every dayMoving/speaking slowly or being fidgety/restless *Not at allSeveral daysMore than half the daysNearly every dayThoughts you would be better off dead or hurting yourself *Not at allSeveral daysMore than half the daysNearly every dayGAD-7 Anxiety Screening 0 – Not at all 1 – Several days 2 – More than half the days 3 – Nearly every day Feeling nervous, anxious, or on edge *Not at allSeveral daysMore than half the daysNearly every dayNot being able to stop or control worrying *Not at allSeveral daysMore than half the daysNearly every dayWorrying too much about different things *Not at allSeveral daysMore than half the daysNearly every dayTrouble relaxing *Not at allSeveral daysMore than half the daysNearly every dayBeing restless or unable to sit still *Not at allSeveral daysMore than half the daysNearly every dayBecoming easily annoyed or irritable *Not at allSeveral daysMore than half the daysNearly every dayFeeling afraid as if something awful might happen *Not at allSeveral daysMore than half the daysNearly every dayAdditional ServicesHardcopy $20.00Priority Order $30.00Both Hardcopy and Rush Order $40.00Consent and Acknowledgement *I understand that: My provider will determine eligibility after a telehealth evaluation. I understand this is not a psychiatric assessment; The purpose of this evaluation is solely to determine whether I may qualify for an Emotional Support Animal (ESA) or Psychiatric Service Dog (PSD) recommendation letter based on my self-reported history and symptoms. ESA letters are valid for housing under the Fair Housing Act. California law requires a 30-day provider-patient relationship before a letter can be issued. A PSD letter can be issued within a 24hour business day window upon completion of telehealth visit. Our team dedicates significant time and administrative effort to reviewing documentation and preparing the required letters. Please note that once an Established Care Letter is received/delivered all fees are nonrefundable regardless of whether the client later chooses not to proceed with the ESA letter or changes their mind. Submit
