PSD Questionnaire "*" indicates required fields Step 1 of 5 0% Welcome to the first step of qualifying for a psychiatric service dog! This simple questionnaire will just take a few minutes. We and the licensed professional you are paired with will keep your answers strictly confidential – they will never be shared with other third parties. For your peace of mind, if you do not qualify for a PSD Letter, you will get a full refund in accordance with our 100% money back guarantee.First Name (Legal Name)* Last Name* * I confirm that I am 18 years of age or older Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Must be an adult 18+Email* Enter Email Confirm Email Phone Number*Gender* Male Female Other Do you own, or are you considering owning, a psychiatric service dog? Yes No A psychiatric service dog is a dog that has been trained to perform tasks relating to a person’s mental health disability. A PSD letter is solely intended to help you establish whether you have a qualifying disability for a service dog under the ADA and Air Carrier Access Act. The PSD letter does not confirm, verify, certify or represent that you own or will own a service dog. The role of the licensed healthcare professional will be limited to assessing your mental and emotional health. A psychiatric service animal for purposes of the ADA and Air Carrier Access Act is a dog (and no other type of animal) that has been trained to perform tasks relating to a psychiatric disability. A PSD letter is solely intended to help establish whether you have a qualifying disability for a psychiatric service dog under the ADA and Air Carrier Access Act. If you’re not interested in or eligible for a PSD, an emotional support animal may be more appropriate for you. Please send us a message via this form if you run into any issues or technical difficulties with submitting your order. Have you experienced any significant changes in your mood in the past 6 months?* Yes No Please indicate if you have experienced any of the following symptoms in the past 6 months. Difficulty with focus and concentration Irritability and/or agitation and/or anger Fatigue Restlessness Changes in your sleep (ie., sleeping too much or difficulty falling asleep) Muscle tension Depressed mood Elated mood Decreased interest in activities that you once enjoyed Lack of motivation Changes in your weight (ie., significant weight gain or weight loss) Changes in your appetite (ie., eating too much or too little) Feelings of worthlessness or hopelessness Indecisiveness Thoughts or wanting to hurt yourself or others Difficulties with your activities of daily living (eg., preparing meals, paying bills, housekeeping,bathing) Missing work or school or performing poorly at work or school Isolation or changes in your social functioning (ie., not spending time with friends/family) Other None In the last 90 days, how often have you been bothered by these symptoms?Do you have feelings of sadness or depression?* Yes No On a typical day, how long do your feelings of sadness or depression persist? Less than 1 hour 1-3 hours 3-5 hours Greater than 5 hours Do you have feelings of anxiety?* Yes No On a typical day, how long do your feelings of anxiety persist? Less than 1 hour 1-3 hours 3-5 hours Greater than 5 hours Does your anxiety, sadness or depression interfere with any of your major life activities? Yes No 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.If yes, please describe what major life activities have been affected, and how. Have you experienced feelings of intense fear or helplessness after witnessing or experiencing a traumatic event?* Yes No If yes, please indicate if you have experienced any of the following symptoms in the past 6 months. Distressing dreams and/or memories of the traumatic event Flashbacks (ie., feeling that the traumatic event is recurring) Avoidance of negative memories or thoughts associated with the event Difficulty remembering important aspects of the traumatic event Negative thoughts or beliefs about yourself and/or others (eg., “I am bad” or “I can’t trust anyone) Feeling detached or estranged from others Difficulty experiencing positive emotions (eg., love, satisfaction, joy) Reckless or self-destructive behavior Hypervigilance Feeling easily startled Other In the last 90 days, how often have you been bothered by your emotions/symptoms from the traumatic event? Rarely Moderately Often Very Often Other Do the symptoms related to the traumatic event interfere with any major life activities? Yes No 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.If yes, please describe what major life activities have been affected, and how.Have you experienced a traumatic event that you would like to share with your licensed health professional? Have you experienced sudden and unexpected intense fear or anxiety for no apparent reason, or panic attacks, in the past six months?* Yes No If you answered Yes, how often do these anxiety attacks occur? Daily Several times a week A few times per month Never Other Do you often worry that you will have panic attacks in the future? Yes No During your last sudden and unexpected event of intense fear or anxiety, or panic attack, have you experienced any of the following? Increased heart rate Uncontrollable shaking Dizziness or nausea Difficulty breathing Hot flashes or profuse sweating Numbness of extremities (legs, fingers, toes, etc.) None of the above Does your anxiety, worrying, panic attacks or fear of future panic attacks interfere with any of your major life activities? Yes No 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.If yes, please describe what major life activities have been affected, and how.General Medical History: Please list and describe any illness (psychological or physical) you have been diagnosed with and any chronic medical conditions you have.*Write “NONE” if you have not been diagnosed with any illness.Prescription Drug Use: Please list the frequency and dosage of any drugs (OTC, prescription) taken in the last 6 months.*Write “NONE” if you have not consumed any OTC or prescription drugs in the last year.Please use this space to communicate anything else you would like your licensed health professional to be aware of. PSD Letter* Price: Notice Regarding Flights: As a result of rule changes by the U.S. Department of Transportation, many airlines are no longer accommodating emotional support animals. Some airlines will still welcome emotional support animals onboard. Please check with your airline directly prior to booking a flight to see what their latest policy is.EZ Automatic Annual Renewal I opt in for Automatic EZ Renewal at the discounted rate of $125. We recommend all clients opt in for EZ Automatic Annual Renewal so that you are eligible for a discounted renewal rate ($125). Clients who do not opt in for this service will be billed the standard rate ($199) at time of renewal. By opting into automatic annual renewal you will receive a notice in a year that it’s time for your licensed healthcare professional to re-evaluate you and issue an updated letter. This is completely optional and we will email you a month before your renewal date so you may cancel your EZ Renewal plan at any time before the renewal date.Expedited Service – Rush Digital Delivery Expedited Service – Rush Digital Delivery Choose this option if your order is time sensitive and you need your letter ASAP or by a specific time. All Expedited Service orders, including plan, are final and are not eligible for a refund. Redemption Code Please enter your code and click “Apply”HiddenShipping OptionsEmail Delivery Only +$0.00Email Delivery & USPS Priority MailTotal: Credit Card*Card Details Cardholder Name Place of Residence* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial 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Residence Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country If you are in the US, you will be paired with a licensed health professional based on your State. If you are in a different State than what is listed for your shipping address, please email us after you submit your order.How did you hear about us?*OtherMy local shelterBingFacebookGoogleInstagramReferralTwitterLet us know who to thank!If other, please specify Consent Sign up for news, discounts, and activities. We respect your privacy and your inbox.A psychiatric service dog must be individually trained to do work or perform tasks relating to a mental health disability. A PSD letter is solely intended to help me determine whether I have a qualifying disability under the ADA and Air Carrier Access Act and is not intended to be submitted to third-parties. The PSD letter does not in any way confirm, verify, certify or represent that I own or will own a service dog. I understand that neither the healthcare professional I work with nor ESA Doctors can make any representations or certifications about the qualification of my current or future animal as a service dog or its training or temperament. It is ultimately my responsibility to determine whether my dog meets relevant assistance animal law requirements and to certify my dog’s service animal status to third-parties (including airlines). It is unethical to falsely represent a pet as a service animal. I have also read the refund policy which will be strictly enforced if I need to cancel my order.* I have read and agree to the Terms and Conditions, Privacy Policy, and the following: A psychiatric service dog must be individually trained to do work or perform tasks relating to a mental health disability. A PSD letter is solely intended to help me determine whether I have a qualifying disability under the ADA and Air Carrier Access Act and is not intended to be submitted to third-parties. The PSD letter does not in any way confirm, verify, certify or represent that I own or will own a service dog. I understand that neither the healthcare professional I work with nor ESA Doctors can make any representations or certifications about the qualification of my current or future animal as a service dog or its training or temperament. It is ultimately my responsibility to determine whether my dog meets relevant assistance animal law requirements and to certify my dog’s service animal status to third-parties (including airlines). It is unethical to falsely represent a pet as a service animal. I have also read the refund policy which will be strictly enforced if I need to cancel my order.Please send us a message via this form if you run into any issues or technical difficulties with submitting your order.PhoneThis field is for validation purposes and should be left unchanged.
