Online Exam Form Step 1 of 7 14% The exam below is a Psychological assessment evaluation and is comprised of 7 steps that are all required to be completed. It should take about 30 minutes to finish the exam. You must prepare yourself to complete the entire exam from start to finish, as there will be no way of saving your work and coming back to it later. Therefore, if you are not prepared to finish it in its entirety, please come back again when you have enough time to complete it. This exam is also MOBILE FRIENDLY so you will be able to use your phone if need be. Once you hit submit and complete your exam, please allow no longer than 2 business days for the mental health professional who reviews it to contact you with your results. If you are not approved, you will receive a same-day 100% refund. Part I: Personal InformationFirst Name*Last Name*Date of Birth*Street Address*Phone Number*Email* City**-- Select a State --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code*Gender*MaleFemaleHow did you hear about us?*-- Make a Selection --CraigslistGoogleYahooBingFacebookTwitterReferralAnimal RescueOtherIf selected other, please specify:What's your current occupation? Please write your current occupation or if unemployed or a student please explain,*Marital Status*MarriedSingleDivorcedWidowedPreferred Emotional Support Pet*DogCat(Please specify if wanting more than one pet in the "other" box. Payment MUST be made for each pet, EX: 2 dogs) PLEASE CONFIRM THE INFORMATION ABOVE REGARDING SPELLING OF YOUR NAME, DATE OF BIRTH, EMAIL ADDRESS, AND GENDER ARE ENTERED AND SPELLED CORRECTLY. ANY ERRORS WILL CAUSE COMPLICATIONS WITH THE APPROVAL PROCESS AND IF APPROVED, THERE WILL BE A $25 CHANGE/ EDIT FEE. By filling out this online medical exam, I understand that by not providing as much detail as possible with the following answers, can result in denial and/ or significantly prolong the approval process.Required* Agree Section 2: General and Mental Health1. Do you feel that you have a debilitating mental health condition that qualifies you to obtain an emotional support animal under U.S. law?*YesNoIf you answered yes to the above question, please describe what debilitating emotional/mental health condition(s) you have below.2. Have you ever been formally diagnosed with a mental-health related condition by a medical professional? (Examples include: anxiety, depression, post-traumatic stress disorder, insomnia, bi-polar disorder, just to name a few.)*YesNoIf you answered yes to the above question, please write below which mental health condition(s) you were diagnosed with. (Examples include: anxiety, depression, post-traumatic stress disorder, insomnia, bi-polar disorder, just to name a few.)3. Has there been a major life event in the last year that has caused you great psychological stress? (Examples include: divorce, a break-up, financial troubles, unemployment, or a death in the family)*YesNoIf you answered yes to the above question, please list the major life event(s) below and how it has impacted you:4. Have you personally experienced any external physical symptoms over the last year? (Examples include: shortness of breath, sweating, trembling, crying, vomiting, etc..)*YesNoIf you answered yes to the above question, please be as specific as possible in describing your symptoms and list the month and year that the symptoms began.5. Do you feel that your emotional/mood condition negatively impacts your ability to carry put your day-to-day activities such as: walking, sleeping, working, learning, concentrating, focusing, communicating, reading, or standing?*YesNoIf you answered yes to the above question, please list below which daily activities you are unable to perform due to extreme stress or another emotional condition and how it has impacted your life. Section 3: General Medical History:1. Have you ever been diagnosed with a condition or illness not related to mental health?*YesNoIf you answered yes to the above questions, please list below what you have been diagnosed with in the past.2. Are you currently taking any prescription medications, herbs, homeopathic or holistic treatments?*YesNoIf you answered yes to the above question, please list ALL medications/treatments you are currently taking as well as dosage.3. Would you consider yourself to be in good physical health over the past 12 months?*YesNoIf you answered No to the above question, please list which physical ailments you have endured over the last year. (Examples: cancer, broken bones, heart condition, stroke, just to name a few)4. Do you currently consume alcoholic beverages?*YesNoIf you answered yes to the above question, please describe below how often and how much alcohol is consumed when drinking.5. Do you currently use illicit drugs?*YesNoIf you answered yes to the above question, please describe which drug(s) is used and how often you use it. Section 4: Major Depression1. Do you feel that you derive little pleasure in doing routine activities anymore?*YesNoIf you answered yes to the above question, please describe which routine activities are impacted by your depression.2. Do you feel depressed on a daily basis?*YesNoIf you answered yes to the above question, please list below the month and year the symptoms first appeared.3. Are you having trouble falling or staying asleep, or sleeping too much?*YesNoIf you answered yes to the above question, please describe when the symptoms started below and how these particular symptoms are impacting your life.4. Do feel overly tired throughout your day with little amounts of energy?*YesNo5. Do you feel that you have a tendency to overeat or undereat?*YesNoIf you answered yes to the above question, please describe below the nature in which you over or undereat and the date the symptoms first appeared.6. Do you typically feel bad about yourself / or that you are a failure / or have let yourself or your family down?*YesNoIf you answered yes to the above question, please explain below how often this feeling occurs and which events or situations give rise to these feelings.7 .Do you have difficulty concentrating on things, such as reading the newspaper or watching television?*YesNoIf you answered yes to the above question, please list when the symptoms first appeared.8. Have you ever thought that you would be better off dead or of harming yourself in some way?*YesNoIf you answered yes to the above question, please list below the situation(s) or event(s) that first gave rise to these thoughts and the month and year that they first occured.9. Do you currently consider yourself to be suicidal at the present time? If so, do you have a plan to carry it out?*YesNoIf you answered yes to the above question, please describe below the nature of your plan.10. Does your major depression negatively impact your school, work, family life, or ability to carry out a reasonably normal lifestyle?*YesNoIf you answered yes to the above question, please describe in detail how it impacts your life below. Section 5: Generalized Anxiety & Panic Disorder1. Do you experience sudden episodes of intense and overwhelming fear that seem to come on for no apparent reason?*YesNoIf you answered yes to the above question, do you experience any of the following symptoms during these episodes: racing heart, chest pain, difficulty breathing, choking sensation, lightheadedness, tingling or numbness? Please describe below which symptoms apply to you:2. Do you worry about something terrible happening to you, such as embarrassing yourself, having a heart attack or dying when having an episode of anxiety?*YesNoIf you answered yes to the above question, please describe the event or situation that first gave rise to your anxiety episodes and list the month and year in which the symptoms first appeared.3. Do you worry about having future episodes of anxiety or panic?*YesNoIf you answered yes to the above question, please describe below which symptoms begin to surface whenever you start to worry about future episodes of anxiety or panic. (Examples include: Heavy breathing, shortness of breath, feeling that you will have a heart attack, sweating, etc..)4. Do you worry about a number of events or activities (such as work, family life, or a school performance)?*YesNoIf you answered yes to the above question, please describe the nature of this worry:5. Is it difficult to control the worry?*YesNoIf you answered yes to the above question, please describe how you have been attempting to control your worries.6. Do you feel as though you have two or more of these symptoms? (Feeling restless or on edge, being easily fatigued, having difficulty concentrating, feeling irritable, muscle tension, having difficulty falling or staying asleep, or restless unsatisfying sleep?*YesNoIf you answered yes to the above question, please list below which two or more symptoms from the previous question you have.7.Have you experienced or witnesses a frightening traumatic event either recently or in the past?*YesNoIf you answered yes to the above question, please describe the nature of the event without going into too much detail.8. Do you feel that your overall anxiety negatively impacts your school, work, family life, or your ability to carry out a reasonably normal lifestyle?*YesNoIf you answered yes to the above questions, please describe how this anxiety has impacted your life.1. Have you experienced or witnessed an event in your past that was any or all of extremely scary, horrifying, assaulting, and/or life-threatening?*YesNo Section 6: Post Traumatic Stress DisorderIf you answered yes to the above question, please explain below the nature of the situation or event (s) and the month and year they occured.2. Do you have recurrent and distressing memories of the event, even when you try not to think about it?*YesNoIf you answered yes to the above question, please describe below the symptoms you experience when you recall these traumautic events.3. Do you have recurrent dreams of all or parts of the trauma?*YesNo4. Do you sometimes feel like you are experiencing some part, parts and/or all of the traumatic event over again?*YesNoIf you answered yes to the above question, please describe below how often you experience these feelings and in which setting the feeling usually occurs. (Examples include: work, school, family life, etc)5. Do you sometimes find yourself feeling traumatized or very frightened about something and cannot associate any memories with the feeling?*YesNoIf you answered yes to the above question, please describe below the month and year you first started losing your memory as it relates to your fright.6. Are you making efforts to avoid thoughts, feelings or talking about the trauma?*YesNoIf you answered yes to the above question, please describe below what you typically do to avoid recalling the past traumatic event(s).7. Do you avoid certain places, people, events and/or situations because they trigger (or might trigger) thoughts of the trauma?*YesNo8. Are you unable to recall important aspects of the trauma?*YesNoIf you answered yes to the above question, please list the month and year in which you first experienced your inabilty to recall important aspects of the trauma.9. Do you feel detached or estranged from yourself and/or others?*YesNoIf you answered yes to the above question, please describe below when you first began feeling this way.10. Are you experiencing any problems falling or staying asleep?*YesNo11. Are you having trouble concentrating, being irritable or jumpy?*YesNoIf you answered yes to the above question, please describe below which symptom(s) in the previous question you have and the month and year you first began noticing that these symptoms were becoming a problem.12. When you think about the future, do you get a sense that it will be shortened for some unknown reason?*YesNoIf you answered yes to the above question, please list why you feel that the future will be shortened for some unknown reason. Section 7: SOCIAL PHOBIAS1.Do you have difficulty speaking in front of groups or a fear of talking to strangers in general?*YesNo2.If you answered yes to the above question, please describe the difficulty as it relates to you below.3.Does the fear in the previous question cause you to have debilitating anxiety?*YesNoIf you answered yes to the above question, please describe below the symptoms associated with your anxiety.4. Are you afraid of embarrassing yourself in public or in front of others?*YesNoIf you answered yes to the above question, please explain below why you feel this way.5. Has your fear of embarrassing yourself in public caused you to avoid your daily responsibilities such as work, school, or any other public events?*YesNoIf you answered yes above, please describe below what major life activities have been impacted by your social phobias? Examples include: Walking, talking, lifting, reading concentrating, communicating, sleeping, and/or writing)6. Are you afraid of flying on a commercial airliner?*YesNo7. Do you get anxious and worried if you fly?*YesNoIf you answered yes to the above question, please describe the nature of your anxiety and worry below.8. Do you avoid flying when possible?*YesNo9. In your past and/ or present life experiences, has had having an animal helped alleviate/ ameliorate your complaints, problems or issues, and is that the reason in which prompted you to submit this medical exam?*YesNoIf you answered YES above, please explain further in detail.Choose a Plan:*Compassion Plan - $199 (Covers 1 Pet Only)Care Plan - $159 (Covers 1 Pet Only)Travel Plan - $149 (Covers 1 Pet Only)Additional PetsSelect1 Additional Pet2 Additional Pets3 Additional Pets4 Additional Pets5 Additional Pets6 Additional Pets7 Additional Pets8 Additional Pets9 Additional Pets10 Additional PetsDo you have or want more than 1 pet as an ESA? Get a discount of ONLY $99 for each additional pet!Would you like a hard copy of your letter sent via USPS?*ESA Letter via USPS Standard +$10.00ESA Letter via USPS PRIORITY w/Tracking +$20.00No Hard Copy * We will email you an ESA PDF letter regardless of what option is selected. The Hardcopy of the ESA letter is printed on special 67lb weighted paper and should be used when traveling overseas. ID Card Sample ESA ID Card Mailed via USPS?*1 ESA ID Card via USPS Standard2 ESA ID Cards via USPS Standard3 ESA ID Cards via USPS StandardNo ID CardPet Name*Pet BreedPlease enter breed like this, "terrier" or "terrier/poodle" and leave out american or any other additional info like "american" or words "with" etc.Pet Weight*Pet Image*Accepted file types: jpg, png.Pet #2 Name*Pet #2 Breed*Pet #2 Weight*Pet #2 ImageAccepted file types: png, jpg.Pet #3 Name*Pet #3 Breed*Pet #3 Weight*Pet #3 Image*Accepted file types: png, jpg.Optional Same Day Service Same Day Rush Service Do you want or need this approval process expedited to ensure that you get your approval letter within 24 hours if you are approved? Get your submission to the top for a rush fee of ONLY $49.95!Total $0.00 Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Very Important: Make sure that the address and zip code entered below match with what the Credit Card you are using has on file. If it does not match, the payment will not get approved and you will have to start the entire process over from the beginning.Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Coupon Required* BY CHECKING THIS BOX I UNDERSTAND THAT I HAVE ANSWERED THE QUESTIONS ON THIS QUESTIONNAIRE TO BE TRUE AND ACCURATE OF MY EMOTIONAL AND MENTAL HEALTH. * BY CHECKING THIS BOX I UNDERSTAND THAT I AM GIVING MY CONSENT FOR THE DOGTOR TO SUBMIT THIS QUESTIONNAIRE TO AN INDEPENDENT LICENSED MEDICAL PROFESSIONAL IN THEDOGTOR’s REFERRAL NETWORK TO REVIEW AND EVALUATE THIS QUESTIONNAIRE. * BY CHECKING THIS BOX I UNDERSTAND IF I AM APPROVED FOR AN EMOTIONAL SUPPORT ANIMAL(s), I WILL NOT BE ENTITLED TO ANY REFUND AMOUNT FOR ANY REASON. Attention: You must submit payment in order for this medical exam to be evaluated.