Medical Questionnaire

Step 1 of 8

The following online medical questionnaire is a HIPAA compliant Psychological assessment evaluation, and it is required to be completed in order to be reviewed from a medical professional who is licensed in the state you live, and/ or the state you will be moving to. The questions you will be asked to answer, are the same types of questions you would answer with pen and paper on a clipboard in a waiting room, as well as the same sort of questions that a licensed medical professional would ask you in person. It shouldn’t take you that long to complete, but PLEASE be thorough and detailed with your answers, and PLEASE be as honest as possible.

Please prepare yourself to complete the entire medical assessment from start to finish, as there will be unfortunately no way of saving your work and coming back to it later. Therefore, if you are not prepared to finish it now, please come back when you have enough time to complete it. This online medical questionnaire is also MOBILE FRIENDLY so you will be able to use your mobile phone or tablet. However, please make sure you have a STRONG and stable Wi-Fi or mobile service connection, for if lost or disrupted, your medical questionnaire could also be lost, and you would be forced to start over again from the beginning.

When you are finished with the medical assessment and select the appropriate ESA/ PSD plan to your liking, you will then make payment. As soon as that is done, your medical questionnaire will be immediately sent to the appropriate medical professional who is licensed in your state for review! Please allow 24-72 hours for the medical professional to review you submission and contact you with your APPROVAL results. However, if needed, we do offer an optional RUSH PRIORITY service, that will prioritize the review of your medical questionnaire, where you can receive your ESA/ PSD approval letters within 24 hours! If you are not approved by the medical professional, you might be asked to provide further information. If you are not able to do so, you will receive a same-day refund.
Part I: Personal Information
First Name*
Last Name*
Date of Birth*
Phone Number*
Email Address*
Gender*
Current Mailing Address*
APT/UNIT #
City*
-- Select a State --*
Zip Code*
Country*
Marital Status*
Are You Moving Soon ?*
To What State?*
When ?*
I CONFIRM MY PERSONAL INFORMATION AND CURRENT MAILING ADDRESS IS CORRECT*
- I CONFIRM MY PERSONAL INFORMATION AND CURRENT MAILING ADDRESS IS CORRECT
How did you hear about us?*
If selected other, please specify:
What's Your Current Occupation? Please Mention If Currently a Student and/ or Unemployed*
Preferred Type of Support Pet(s) ?*
( Select ALL That Apply )
- Dog
- Cat
- Other
Number of Dogs*
Number of Cats
Number of Other
Please, Specify Type of Animal
Hidden
Preferred Type of Emotional Support Pet(s)
- Dog
- Cat
(Please specify if wanting more than one pet in the "other" box. Payment MUST be made for each pet, EX: 2 dogs)
I CONFIRM THE INFORMATION ABOVE REGARDING THE SPELLING OF MY NAME, DATE OF BIRTH, EMAIL ADDRESS, AND GENDER ARE ALL ENTERED AND SPELLED CORRECTLY. ANY ERRORS WILL CAUSE COMPLICATIONS WITH THE APPROVAL PROCESS AND IF APPROVED, THERE WILL BE A $25 CHANGE/ EDIT FEE.

Medical Questionnaire

Step 1 of 8

Part I: Personal Information

Section 2: General and Mental Health

Section 3: General Medical History:

Section 4: Major Depression

Section 5: Generalized Anxiety & Panic Disorder

Section 6: Post Traumatic Stress Disorder

Section 7: SOCIAL PHOBIAS