ESA Questionnaire

This form is not a diagnostic instrument and is solely used to inform the professional you are paired with to contact you. We may use your email address to contact you for transactional assistance – for example, if you do not properly complete the questionnaire or checkout process. The maker and provider of this form does not take responsibility for any liability, loss, or risk incurred as a consequence, directly or indirectly, from the use and application of any of this material. The actions of an emotional support animal is the full responsibility of its owner. By filling out this form and pressing next, you are providing your consent to to store and review your questionnaire for the purpose of connecting you with a licensed health professional so they can review your request. is not guaranteeing that a mental health professional will issue a recommendation for an ESA to you and will not influence the decision of the licensed mental health professional you are paired with. is not a medical clinic and we are not doctors, counselors, therapists, psychologists, lawyers, etc. is a technology company and does not make assessments, diagnosis, or provide any form of medical or mental health treatment or legal advice. Your privacy is important to us and we take it seriously. If you have any questions or concerns, contact us at