Online Exam Form Step 1 of 7 14% The following exam consists of seven parts with 74 total questions. Each question MUST be answered. If the question does not apply to you, answer “No” or “None” in the appropriate field. If a question is left blank, you will not be able to submit the exam. Please allow 24 - 48 hours for your results and your emotional support animal letter if approved. If you are not approved, a 100% REFUND will be issued immediately.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 --CraigslistGoogleFacebookTwitterReferralAnimal RescueOtherIf selected other, please specify:Marital Status*MarriedSingleDivorcedWidowedPreferred Emotional Support Pet*DogCat(Please specify if wanting more than one pet. Payment MUST be made for each pet) Part II: General Mental and Physical HealthSometimes major life events can cause symptoms similar to a psychological illness. For example, the death of a loved one can understandably have negative effects on one’s mental health. Emotions of grief, sorrow, and anxiety are not unusual in such a situation and are a normal part of the healing process in the near term. Please list any major events that have been a significant source of stress or anxiety in your life during the last year. Examples may include: death of family member, loved one or acquaintance, relationship problems (divorce, break up with significant other), financial problems, loss of employment or home, or ANY event that has been a major source of stress. Please provide as much information as possible. If you have not experienced any events that have caused significant stress or anxiety in the last year, then please write “None” below.*In the past year have you experienced any significant external emotional symptoms such as crying, trembling, and shortness of breath, headaches, or any other negative symptom of your emotions? Please provide as much information as possible and give approximate dates, locations, and circumstances if possible. If you have not experienced any external emotional symptoms in the last year then please write “None” below.*Is there one or more major life activity that you are unable to perform (or have great difficulty performing) because of problems caused by stress or any other emotional problem? (Major life activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working).*YesNoIf you answered YES above please: (1) List the major life activity you are unable to perform or have difficulty performing and how you feel it has been affected by your emotional problems. (2) How long has this been occurring for – Please list approximate dates and provide as much information as possible.General Medical History: Please list ANY illness (psychological or physical) you have been diagnosed with. If none, then please write “None” below. Approximate illness date of diagnosis.*Medications: Please list ANY medications that you are currently taking and the dosage if known. If none, then please write “None” below.*General Physical Health: How has your general Physical Health been in the last 12 months? Have you suffered from ANY major physical ailments including but not limited to: Heart Problems, Cancer(s), Diabetes, Organ Failure, Broken Bones, Fever, or Severe Head Aches. If so please explain, if not then please write “None” below.*Drug and Alcohol Use: Similar to Major Life Events, sometimes symptoms of psychological problems can be caused by Illegal Drug use or excessive alcohol consumption. To better understand your current mental health conditions please provide the following information. Alcohol: If you have consumed alcohol in the last 12 months please list the frequency and amount consumed. If none, then please write “None” below.*Illicit Drug Use: If you use ANY drugs please identify the drug, the frequency of use and amount consumed. If none, then please write “None” below.* Part III: Post-Traumatic Stress DisorderHave you ever been exposed to a traumatic event in which your life or someone else’s was actually in danger or you thought your life or someone else’s was in danger?*YesNoIf YES please above please describe what happened and provide as much information as YOU ARE COMFORTABLE providing.Did you experience feelings of intense fear or helplessness after the event?YesNoHave you had recurrent unwanted recollections of the traumatic in last 6 months – including thoughts, dreams or perceptions?*YesNoIf you answered YES above please: (1) Describe your recurrent thoughts, dreams or perceptions. (2) Frequency – How often have you experienced these recurrent thoughts, dreams, or perceptions during the last 6 months? Please provide as much detail as you are comfortable providing.Have you ever had flashbacks or feelings you were reliving the traumatic event even while you’re awake?*YesNoDo you have intense feelings of distress or anxiety when reminded of the traumatic event?*YesNoDo you try to avoid people or places that remind you of the traumatic event?*YesNoDo you try to avoid conversations or thoughts that remind you of the traumatic event?*YesNoSince the traumatic event, have you been much more alert or looking out for possible trouble?*YesNoSince the traumatic event took place, have you had difficulty concentrating?*YesNoSince the traumatic event, have you felt irritable or had outbursts that you had difficulty controlling?*YesNoSince the traumatic event took place, do you have difficulty sleeping?*YesNoSince the traumatic event took place, are you less interested in activities you previously enjoyed?*YesNoSince the traumatic event took place, have you had difficulty meeting new people?*YesNoDo reminders of the traumatic event cause physical symptoms of distress, such as trembling, shortness of breath, increased pulse, muscle aches, or sweating?*YesNoDo you feel your future life may be negatively impacted as a result of the traumatic event?*YesNoSince the traumatic event took place, have you had difficulties showing emotions of love or affection?*YesNoIn the last 90 days, how often have you been bothered by your emotions/symptoms from the traumatic event?*RarelyModeratelyOftenVery OftenDo the unwanted thoughts or feelings related to the traumatic interfere with any major life activity? (Major Life Activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.)*YesNoIf you answered YES above please: (1) List the major life activity you are unable to perform or have difficulty performing and how you feel it has been affected by the unwanted thoughts or feelings related to the traumatic event. (2) How long has this been occurring for? Please list approximate dates and provide as much information as possible. Part IV: Generalized Anxiety DisorderDuring the past six months have you been frequently worried about big or small events in your life?*YesNoIf you answered YES above, how frequently has your worrying caused anxiety or stress in the last six months on a daily basis?Every DaySeveral times per weekA few times per monthNoneIf you answered YES to the question above can you describe what kind of events you worry about and what happens to you when you worry? Please provide as many details as possibleDo people ever say you worry about things too much?*YesNoDo you think you worry about things too much?*YesNoDo you have difficulty controlling your worries or anxiety?*YesNoHow long have you had difficulty controlling your worries in the past 12 months?*Less than 30 days1 - 3 Months3 – 6 MonthsOver 6 MonthsWhen worried, do you frequently feel irritable or on edge for no apparent reason?*YesNoDo you often worry something bad is going to happen to you or someone close to you?*YesNoWhen worried, do you frequently have difficulty sleeping?*YesNoWhen worried, do you have tensions or muscle aches?*YesNoDo you often become tired easily or experience a sudden unexplained loss of energy?*YesNoDoes your worrying interfere with any major life activity? (Major Life Activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.)*YesNoIf you answered YES above, please explain how your worrying interferes with your daily life activities. Please provide as much information as possible. Part V: Panic DisorderHave you ever experienced sudden and unexpected intense fear or anxiety for no apparent reason (panic attack) or institutions where you did not expect it to occur in the past 6 months?*YesNoIf you answered YES, how often do these anxiety attacks occur?DailySeveral times a weekA few times a monthIf you answered YES to the question above please describe your most recent panic attack, what happened? Please provide as much information as possible.Do you often worry that these panic attacks will have negative health consequences – Possible heart attack, losing control, or other debilitating affects?*YesNoDo you often worry that you will experience more panic attacks in the future?*YesNoDuring your last panic attack, did you feel your pulse increase (increased heart rate)?*YesNoDuring your last panic attack, did you experience uncontrollable shaking or trembling?*YesNoDuring a panic attack, did you often feel dizzy or nauseous?*YesNoDuring your last panic attack, did you have difficulty breathing or feel like you were out of breath?*YesNoDuring your last panic attack, did you have hot flashes or experience profuse sweating?*YesNoDuring your last panic attack, did any of your extremities (legs, fingers, toes, etc.) feel numb?*YesNoDuring your last panic attack, did you feel detached from reality, almost like you were dreaming?*YesNoDo your panic attacks or fear of future panic attacks interfere with any of your major life activities? Major Life Activities include, but are not limited to: Caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.*YesNoIf you answered YES above please explain how your panic attacks interfere with your daily life activities. Please provide as much information as possible. Part VI: Sub-threshold Social PhobiasDo you have an intense fear that you will do or say something in front of others that will embarrass you?*YesNoIf you answered YES to the question above please describe specifically what activity you are afraid of performing in front of other people that causes intense fear or anxiety. Please provide as many details as possible.Does your fear in the last question cause you intense stress or anxiety?*YesNoBefore, during or immediately after the feared activity, do you experience any physical symptoms such as shaking, trembling, perspiring or nausea?*YesNoHave you ever completely avoided the activity because of fear or anxiety?*YesNoDoes your fear prevent you from performing or make the task extremely difficult completing?*YesNoDo you think you are more afraid or worried than you should be?*YesNoDoes the feared activity interfere with any of your major life activities? Major life activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.*YesNoIf you answered YES above please explain how the feared activity interferes with your daily life activities. Please provide as much information as possible. Part VII: Major DepressionDo you often feel sad or depressed for unknown reasons?*YesNoIf you answered yes, how often have you felt sad or depressed in the last 30 days?DailySeveral times per weekA few times per monthOn a typical day, how long do your feelings of sadness or depression persist?*Less than 1 hour1 – 3 Hours3 – 5 HoursGreater than 5 hoursNone of the aboveHas your depression or feelings of sadness caused significant changes in appetite, causing you to eat significantly more or less?*YesNoIf you answered YES above, in the last 3 months how long has your appetite been increased or decreased?1 week or less1 - 2 Weeks2 weeks to 1 monthMore than 1 monthHas your depression caused you to gain or lose a significant amount of weight (greater than 5%) in any given month?*YesNoHave you lost interest in activities you previously enjoyed because of feelings of sadness or depression?*YesNoIf you answered YES above, in the last 3 months how long has your disinterest in previously interested activities persisted for?1 week or less1 – 2 Weeks2 weeks to 1 monthMore than one monthDo you often have feelings of worthlessness or often experience low self-esteem?*YesNoIf you answered YES above, in the last 3 months how often have you experienced feelings of worthlessness or low self-esteem?1 week or less1 – 2 Weeks2 weeks to 1 monthMore than 1 monthDo you have difficulty sleeping or sleep too much? If so, in the last 3 months how often do you experience difficulty sleeping?*DailySeveral times per weekA few times per monthDo you often feel fidgety or have problems sitting still?*YesNoDo you often feel fatigued or suffer from an unusual loss of energy? If so how often do you experience fatigue?*DailySeveral times per weekA few times per monthDo the unwanted feelings of sadness or depression interfere with any major life activity (Major Life Activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.)*YesNoIf you answered YES above please explain below in what way the depression interferes with your daily life. Please provide as many details as possible.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 questionnaire?*YesNoIf you answered YES above, please explain further in detail.Does your future seem hopeless?*YesNoHas the pleasure and joy gone out of your life?*YesNoDo you have difficulty making decisions?*YesNoDo you feel sad, blue and unhappy?*YesNoDo you feel fatigued?*YesNoDoes it take great effort for you to do simple things?*YesNoDo you feel like a guilty person who deserves to be punished?*YesNoDo you feel lifeless, more dead than alive?*YesNoDo you feel caught or trapped?*YesNoDo you spend time thinking about how you might kill yourself?*YesNoIf you answered yes, do you have a plan? Do you have a means? Pricing Plans Compassion Plan No Expiration ESA Housing Letter! No Expiration ESA Travel Letter! Patients Are NOT Required To Be Re-Evaluated! *Most Popular Plan. $199 Care Plan 1 Year ESA Housing Letter ONLY. Expires 12 Months From Date of Approval. * Patients MUST Be Re-Evaluated Every 12 Months. * Does NOT Include ESA Travel Letter. $159 Travel Plan 1 Year ESA Travel Letter ONLY Expires 12 Months From Date of Approval * Patients MUST Be Re-Evaluated Every 12 Months * Does NOT Include ESA Housing Letter $149 Choose a Plan:*Compassion Plan $199.00Care Plan $159.00Travel Plan $149.00Additional PetSelect1 Additional Pet2 Additional PetsOptional Same Day Service Same Day Service 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 GrenadinesSamoaSan 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 This page is unsecured. 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