Personal Information

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Pet
Details

Tell us more about your pet.

Questionnaire

Answer a few simple questions.

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We’re Almost Ready—Tell Us About You

Let’s Start by Finding Your State!

Select from these popular states for a quick start

California

New York

Texas

When’s Your Birthday?

What Gender Do You Identify As?

Male

Female

Other

Select the Type of Your Pet Companion

Dog

Cat

Other

Help Us Get to Know More About Your Pet

What Do You Call Your Beloved Companion?

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

Sometimes

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

Sometimes

Often

Always

Over the past two (2) weeks, have you had thoughts of suicide?

YES

Note: (If Yes then the person is disqualified and ESA letter can’t be prescribed) The person should seek help elsewhere.

That’s it! Now simply confirm your information as correct.

Enter your name in the signature box below to verify the accuracy of your answers to the best of your knowledge.

I, Myles, hereby certify that the information I have submitted to RealESAletter.com is truthful and accurate to the best of my knowledge.

My signature below confirms my understanding that my information will be digitally and securely forward to a licensed mental health professional who will assess my suitability for an Emotional Support Animal. I further agree that my responses here may be viewed by a therapist and the administrative professionals at RealESAletter.com for the purpose of issuing my ESA Letter.

I hereby agree to all RealESAletter.com terms and conditions and give my permission for their personnel to convey my information to a licensed therapist who may prescribe treatment of any issues appropriate to the issuance of my ESA letter.