Our Questionnaire

Please answer the questions below to see if you qualify for an Emotional Support Animal Letter! If you have any questions of your own you can reach out to us by phone at 323-430-4200.

Name

First Name

Last Name

What state do you live in?

Are you over the age of 18?

Does being with your pet help you reduce stress?

Does being with your pet improve your mood?

Do you feel sad when you are not with your pet?

Have you experienced signs and symptoms of depression in the last 6 months?

Have you experienced significant anxiety or panic in the last 6 months?

Are you currently experiencing significant stress or difficulty adjusting to a major life change?

Is your stress or mood impacting your social, occupational, or educational performance or ability to engage in these activities?

Have you experienced a major life change in the last 6 months?

In the last 2 weeks, how often have you had less interest or pleasure in doing things you usually like to do?

In the last 2 weeks, have you been prone to outbursts, mood swings or periods of negativity?

In the last 2 weeks, how often have you avoided situations that make you nervous?

In the last 2 weeks, have you felt detached or distant from yourself or other people?

Describe in detail how your pet(s) helps you with reducing stress and anxiety in your life?

How many animals would you like to register as an emotional support animal?

If you are applying for more than one pet please fill out our questionnaire for one of your pets and we will reach out to collect additional information about your other pet(s).

What type of pet are you seeking an ESA for?

If you selected other for your pet type please enter their type here. If you selected cat or dog please leave this blank.

What breed is your pet?

What is your pet's name?

How much does your pet weigh?

Thank You

Thank you for completing our questionnaire. We will reach out to you shortly. If you have any questions please feel free to write them in the space below or reach out to us by phone at 323-430-4200.

Our Questionnaire

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