Renewals Page

Currently living in the State of:*
This option is very important: If you are moving to another state, please select that state. Our mental health professionals utilize “Telehealth” (telemedicine/telepsychology) which is a collection of means or methods for enhancing health care, public health, and health education delivery and support using telecommunications technologies.
Patient First Name*
Patient Middle Name
Patient Last Name*
How many Pets
Pet #1 Type
Pet #1 Breed
Pet #1 Weight
Pet #1 Name
Pet #2 Type
Pet #2 Breed
Pet #2 Weight
Pet #2 Name
Pet #3 Type
Pet #3 Breed
Pet #3 Weight
Pet #3 Name

Email Address*
Enter Email Confirm Email
Marital Status*
- Married
- Divorced
- Single
- Widowed
Gender*
- Male
- Female
Birthdate*
Your date of birth
Example: 12/01/1995 (Month/Day/Year)
Phone (Cell Preferred)*

Previous Doctor's Name*
Please select the name of the doctor or therapist that wrote your ESA letter.
Previous Patient ID Number
Please locate your patient ID number (starting with 149-xxxxxxx)
Attending a College/University?
Warning! Please don't submit the exam if you plan to live at in a dormitory or college owned property.

1) I am under high levels of Stress.*
2) I feel Overwhelmed by my current Life circumstances.*
3) I find myself feeling discouraged and pessimistic about my future.*
4) I find myself depressed and or saddened by my current life circumstances.*
5) I feel beat down and burnt out in my current life circumstances.*
6) I feel unhappy in my current life circumstances.*
7) I find myself worrying about my future, my finances, or my family.*
8) I feel frustrated and uneasy in my current life circumstances.*
9) I feel burdened by my current life circumstances.*
10) I find myself tense and up tight in my current life circumstances.*
11) My stress level is interfering with my work.*
12) My stress level is interfering with my sleep.*
13) My stress level is interfering with my ability to focus and concentrate on what I have to do.*
14) I turn to Alcohol, Food or drugs to comfort me in my current life circumstances.*
15) I am finding that Anxiety and restlessness are disrupting my everyday Lifestyle.*
16) I find myself irritable and often impatient in my current life circumstances.*
17) Do you find yourself lonely in your current life situation?*
18) Do you wish you had more and deeper emotional support systems?*
19) Does your stress level interfere with your communication with your loved ones, friends, or coworkers?*
20) I am subject to outbursts, Mood swings, or periods of negativity in my current life circumstances*
21) Which Life events have caused you significant stress this year?*
Acceptance score
The therapist/doctor requires a minimum threshold value of 20 or higher to property approve your request. Note: Each question above has a score of 1 to 4. Increase your score by reviewing the top 20 questions again. The Next button will appear once the threshold has been achieved.

Please describe your stress levels in detail.*
Have you ever seen a doctor for your emotional or mental health? Also, have you ever taken medication for your mental health?*
If so, please list the medication (e.g., Zoloft, Celexa, Effexor, Ritalin, etc.).
How does your animal support you when you are experiencing anxiety, depression or other emotional issues? Please give specific examples.*
Have you ever received a mental health diagnosis such as depression, anxiety, PTSD, etc.?*
How does your mental or emotional disability directly impact your daily life and functioning?*
If you are requesting more than one animal, please describe in detail how each animal provides a uniquely distinct relief of symptoms of your mental disability.

Hard Copy of ESA Letter to be Mailed via USPS
- No
- ESA Letter Only USPS Standard
- ESA Letter Only USPS PRIORITY w/Tracking
- ID Card & ESA Letter PRIORITY w/Tracking
PSD letter(s) will also be mailed out with this option.

Note: The hardcopy ESA letter is printed on special parchment 24 lb. weighted paper and should be purchased when traveling overseas or if your landlord requires such.

The durable optional Photo ID card is made from the same material as your common credit card.

The file uploader box will display below only if you select the ID card option. Email support@emotionalpetsupport.com anytime only if you don't have photo(s) of your animal at this time.
Select type of ID card for Animal 1
ESA ID cards are for housing (ALL ANIMALS).
PSD ID cards are for housing and air travel (ONLY DOGS).
Select type of ID card for Animal 2
ESA ID cards are for housing (ALL ANIMALS).
PSD ID cards are for housing and air travel (ONLY DOGS).
Select type of ID card for Animal 3
ESA ID cards are for housing (ALL ANIMALS).
PSD ID cards are for housing and air travel (ONLY DOGS).
Upload a Photo for each animal.
Drop files here or
Max. file size: 256 MB, Max. files: 5.
Please allow time to upload your photo(s) before submitting the exam.

Comments / Special Instructions
Please write any additional comments or instructions within this box.
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Airline Optional Forms
- Airlines no longer require forms
Additional Housing Form
- Reasonable Accommodation Form
Optional service to use only if your landlord has their own form that needs to be filled out by our doctor (RAF: Reasonable Accommodation Form). You can always request this option in the future if you're not sure now.
Emotional Support Animal Certificate
- ESA Cert Emailed PDF + Mailed Via USPS
This ESA Certificate is only recommended for apartment/housing use. PSD (Psychiatric Service Dog) Certificates are only available after you have been approved by one of our therapists and can be requested at a later date.
Rush Option*
Optional review timeframe. Our therapists and doctors review cases 7 days a week / 365 days a year. We do our best to provide your digital ESA letter within the selected timeframe.
Pick Your Plan*
- ESA Housing Letter $59
- PSD Air Travel Letter $59
- ESA Housing Letter & PSD Air Travel Letter $110
Note: JetBlue Airlines is not supported at the time.
Dog Training Options
Full Online Training ($79): This optional online training class is recommended for emotional support dogs and/or psychiatric support dogs. Either at home, flying, or in public places, we recommend that your dog be properly trained for all environments. After you have been approved by one of our mental health professionals, a link to the online video training class will be emailed. At the end of the dog training class (passing each session successfully), you simply upload a video of your dog responding to the required commands for which your assigned dog trainer will review. If no feedback is required, the dog trainer will approve and share their contact information. Note: The DOT form for PSDs is also covered with this option for those planning to fly with their dog and require that the DOT form include the dog trainer’s information.

Six Major Benefits of Dog Training
• It is significantly safer for your dog.
• It's safer for your home.
• It builds a lasting relationship between you and your dog.
• It's easier when you take your dog out in public.
• It's easier for the vet to work with your dog.
• You can help other dog owners.

Video Courses include:
1. Creating a bond between you and your dog.
2. Prepares your dog to pay attention to future commands.
3. Teach your dog to sit.
4. Teach your dog to lie down.
5. Teach your dog to heel.

PSD for Air travel Only ($39): If this option is selected and your dog is already trained, you will be asked to email or upload a video of your dog responding to basic commands (sit, stay or wait, come, and stop) after your exam has been approved. This will help ensure that your dog meets the requirements to be considered as a Psychiatric Service Dog (PSD) and DOT (Department of Transportation) form. Afterwards, your assigned trainer will provide all required DOT contact information so you can complete the DOT form.

Billing Address*
Street Address Address Line 2 City State ZIP Code
Shipping Address Different?
- Select this option if your shipping address is different from your billing address
NOTE: We no longer ship internationally.
Shipping Address
Street Address Address Line 2 City State ZIP Code

FOR AIR TRAVEL ONLY

THIS ONLY APPLIES IF YOU HAVE A DOG THAT NEEDS TO TRAVEL WITHIN THE CABIN OF AN AIRPLANE NOW OR IN THE FUTURE.
DOT (Department of Transportation) allows Psychiatric Service Dogs (PSD) to travel onboard airplanes. Please review the Training Checklist below:

Your dog does NOT engage in any of the following:
1) Growling or inappropriate, excessive barking
2) Nipping or biting
3) Showing or baring teeth
4) Lunging at other people or dogs
5) Being out of handler’s control
6) Inappropriately eliminating (urinating or defecating)
7) Enters and exits any form of transportation in a safe manner.
8) Is able to travel in any form of transportation in a controlled manner.
I attest to all above statements to be true. ONLY FOR DOGS
- I AGREE
Skip this if you don't have a dog.
Signature
By signing this form, the applicant is affirming or swearing that all information contained in the form is true and correct.

Note: If you are unable to sign it now, we will follow up with you later.

Types of licenses: D.O. (Doctor of Osteopathic Medicine), LCSW (Licensed clinical social worker), LPC (Licensed professional counselor), MA (Master of Arts in counseling), MD (Medical doctor), MFT (Marriage and Family Therapist), and MHC (Mental health counselor).
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Currently living in the State of*
Patient Consent To The Use of Telepsychology*
- I agree with the statement
I have read and understand the information provided regarding tele-psychology/tele-medicine, I agree to share my information with my assigned mental health professional per the HIPAA privacy rights. I hereby give my informed consent for the use of tele-psychology/tele-medicine in my care. CLICK HERE TO VIEW CONSENT FORM I confirm that this/these animal(s) has been trained to behave in a public setting and takes my direction upon command. I assume full responsibility for the behavior of this/these animal(s), including its interaction with others. I also understand that I accept all liability to any damages resulting from any misbehavior by my animal(s).
Hidden
Approved? (Admin-only)
- Approved

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Renewal and Annual Re-Assessment

Step 1 of 11