Renewals Page

Pick Your Plan*
- ESA Housing Letter & PSD Air Travel Letter $110
- ESA Housing Letter $59
- PSD Air Travel Letter $59
Patient First Name*
Human Name (Not Animal's Name)
Patient Middle Name
Patient Last Name*
Current legal last name
How many Pets
Only dogs qualify for Air Travel (PSD Status).
Cats, Dogs, and Birds all qualify for the apartment/housing ESA letter.
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.?*

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 [email protected] 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.
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
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
- 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
Sample:
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.

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).
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.
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).
Approved? (Admin-only)
- Approved

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TeleHealth requires reassessment

Renewal and Annual Re-Assessment

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