Please Complete This Questionaire ESA Questionnaire Personal Information Name * Name First First Last Last Date of Birth (mm/dd/yyyy) * Phone * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Your Pet Do you have a pet? * Yes No What is the name of your pet? * What type of pet do you have? Tell us about you Over the past two (2) weeks, how often have you had little interest or pleasure in doing things that you usually like to do? * Never Rarely Sometimes Often Always Over the past two (2) weeks, how often have you felt sad or depressed? * Never Rarely Sometimes Often Always Over the past two (2) weeks, how often have you felt more angry or more irritated than usual? * Never Rarely Soemtimes Often Always Over the past two (2) weeks, how often have you felt worried, anxious, or on edge? * Never Rarely Sometimes Often Always Over the past two (2) weeks, how often have you felt afraid or panicked? * Never Rarely Sometimes Often Always Over the past two (2) weeks, how often have you had irregular sleep? (Sleeping too much or too little) * Never Rarely Sometimes Often Always Over the past two (2) weeks, how often have you been acting impulsively? (Shopping too much, sudden use of drugs or alcohol, feeling like you’re “on top of the world”) * Never Rarely Sometimes Often Always Over the past two (2) weeks, how often have you avoided situations that make you nervous? * Never Rarely Sometimes Often Always Over the past two (2) weeks, how often have you heard things other people couldn’t hear and seen things other people couldn’t see? * Never Rarely Sometimes Often Always Over the past two (2) weeks, how often have you felt paranoid or fearful you are in danger? * Never Rarely Soemtimes Often Always Over the past two (2) weeks, have you had thoughts of suicide? * Never Rarely Sometimes Often Always Section Email Congratulations! You are a Good Candidate for an Emotional Support Animal Letter. Type Of ESA Letter Which ESA Letter would you like? (select one) * Housing & Travel $199.99 Housing $149.99 Travel $149.99 Get Your ESA Letter If you are human, leave this field blank.
