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I have been under high levels of StressNoYesI feel Overwhelmed by my current life circumstancesNoYesI find myself depressed and or saddened by my current life circumstancesNoYesI turn to Alcohol, Food, or drugs to comfort me in my current life circumstancesNoYesI am subject to outbursts, mood swings, or periods of negativity in my current life circumstancesNoYesHave you wished you were dead or have you felt that you or your family would be better off if you were dead?NoYes Optional: Name First Last Optional: Email Congratulations! You are pre-qualified for an ESA letter. Please click on the "Submit" button below to start the process today. You will be assigned to a mental health professional that will work with you on the ESA processPlease write down discount code " ESA2019 " to receive 10% off. Enter your information above if you wish to be contacted, otherwise, leave it blank when you click submit.Date: 11/20/2019Sorry, but you do not qualify for an ESA letter. You are welcome to retake the exam in the event that you made a mistake. Please click on the "Start Over" button if you wish to retry.Enter your information above if you wish to be contacted, otherwise, leave it blank when you click submit. This iframe contains the logic required to handle Ajax powered Gravity Forms.
