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Emotional Support Animal Prescription Letters Written by Licensed Mental Health Professionals

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TeleHealth requires reassessment
HUD (Housing and Urban Development) and ACAA (Air Carrier Access Act) both require updated ESA letters annually.
New Air Travel Requirements
Many airlines have implemented their own mental health verification forms. Please review the airline forms below.

Renewal and annual re-assessment

Previous Doctor's Name*
Please select the name of the doctor that wrote your ESA letter.
Previous Patient ID Number
Please locate your patient ID number (starting with 149-xxxxxxx)
Patient First Name*
Human Name (Not Animal's Name)
Patient Middle Name
Patient Last Name*
Gender*
- Male
- Female
Birthdate*
Example: 12/01/1995 (Month/Day/Year)

Note: Patients that are minors (under 18 yrs. old). We recommend that the parent or legal guardian complete the exam with their name as the patient instead of the minor’s name. Many landlords take issue to a name that is not on the lease. Some airlines might require additional information which will slow down the process. The adult can mention within the stress input form section the appropriate indicators regarding the minor’s issues but as the point of view from the parent.
Marital Status*
- Married
- Divorced
- Single
- Widowed
Email Address*
Enter Email Confirm Email
Phone (Cell Preferred)*
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?*
22a) In the past few weeks, have you wished you were dead or have you felt that you or your family would be better off if you were dead? (Doctor might contact you if selected)*
22b) In the past week, have you been having thoughts about killing yourself? (Doctor might contact you if selected)*
22c) Have you ever tried to kill yourself? (Doctor might contact you if selected)*
Please describe your stress levels in detail.*
Please list the names of doctors that you have seen and are seeing. List all medications that you are currently taking.*
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 specific diagnosis from a physician, psychologist or counselor, if so, please describe/list the diagnosis(es)?*
Pet Section:
You are not required to own your animal before applying for an ESA letter and can leave the weight, breed, and name fields blank till you get your animal. We can always update the letter later.

Note: Please double check the spelling of your animal's breed and name as we will not. Commonly misspelled names: Shih Tzu, Shepherd, and Chihuahua.
How many Pets
Pet #1 Type
Pet #1 Breed
Pet #1 Name
Pet #1 Weight
Pet #2 Type
Pet #2 Breed
Pet #2 Name
Pet #2 Weight
Pet #3 Type
Pet #3 Breed
Pet #3 Name
Pet #3 Weight
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
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.

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.

USPS Priority is 2 to 4 days depending what State you live in. https://www.usps.com/ship/priority-mail.htm
Upload a Photo for each animal.
Drop files here or
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.
Airline Optional Forms
- American Airlines Special Form
- United Airlines Special Form
- Delta Airlines Special Form
- Alaska Airlines Special Form
- JetBlue Airlines Special Form
- Spirit Airlines Special Form
- Frontier Airlines Special Form
- Allegiant Airlines Special Form
- Hawaiian Airlines Special Form + Modified ESA Letter
Latest 2019 airline travel forms. Our general Air Travel ESA Letter works well with all airlines but If you're planning to fly on any of the above airlines, we recommend that you select the appropriate form option.
You also can order any airline form in the future from the special service link that will be emailed to you.Note for DSM V (5), DSM IV (4), and earlier versions: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition covers all earlier editions IV (4) and earlier. Some airlines might reference the older version but will still accept the current DSM V(5) version.
Please note that some pages require additional information.
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
Sample:
Rush Option*
Reviewed 7 days a week / 365 days a year. From submission time to receiving the electronic PDF ESA letter. Note: Delays will occur if any suicide related questions are answered "yes" as the doctor is required to follow up with you.
Pick Your Plan*
- Apartment Housing & Air Travel ESA Letters
- Apartment Housing ESA Letter
- Air Travel ESA Letter
The renewal plan is $59 for any selection above.
Sub Total
$0.00
Note: Please add your Apartment number/letter to Address Line 2
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PLEASE ENTER YOUR APARTMENT NUMBER/LETTER IN THE ADDRESS 2 FIELD
Shipping Address Different?
- Select this option if your shipping address is different from your billing address
Shipping Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Note: Please add your Apartment number/letter to Address Line 2
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.
Currently living in the State of:*
This option is very important: If you are moving to another state, please select that state. Our doctors 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. Over the past 40 years, telemedicine has been used to bring healthcare services to patients in distant locations. Not only does Telehealth improve access to patients but it also allows psychologists and physicians to expand their reach, beyond their own offices. Note: If you are moving soon, please select the state that you're moving to.
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
Total
$0.00
Credit Card

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Approved? (Admin-only)
- Approved

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Renewals Page was last modified: December 7th, 2018 by Emotional Pet Support Team

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Newport Beach, CA 92660
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Mililani, HI 96789

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