Assessment – CertifyESA

You must 18 or older to complete this assessment.

Yes No

What State do you need Your Letter For

Are you seeking a letter primarily for

ESA Letter / Housing

Both ESA + PSD Letter

PSD Letter / Air travel

Full Legal Name

Date of Birth:

Gender:

Phone Number:

Email Address:

Home Address:

City

State:

ZIP:

Preferred method of contact:

Phone Email Text

How many animals do you have or intend to use for emotional or psychiatric support?

1 2 3

2. Please indicate if you have experienced any of the following symptoms in the past 6 months (check all that apply):

Sleeping Concentration Social interaction Traveling Independently Working or Attending School Emotional Regulation Panic or Anxiety in Public Other

In the last 90 days, please indicate how often you experience the following symptoms: 1. Persistent sadness or low mood