Contact – certifymyesa

Contact Us for ESA Letter

Reach out for your emotional support animal letter today.

1. Name: *

2. Email: *

3. State:

4. Phone : *

Pet Information

7. Pet Name :

8. Pet Breed :

9.Pet Age :

10. Pet Weight:

11. Pet Gender:

12.Comment Box:

13. Request Type:

Housing Request (ESA Letter) $85

Travel Request (PSD Letter-only dogs) -$85

Both (ESA and PSD letter) $130

14. Pre-Screening Questions:

3) Over the past two (2) weeks, how often have you felt afraid or panicked?

Never

Sometimes

Often

Always

4) Over the past two (2) weeks, how often have you had irregular sleep? (Sleeping too much or too little)

Never

Sometimes

Often

Always

5) Over the past two (2) weeks, how often have you avoided situations that make you nervous?

Never

Sometimes

Often

Always

6) 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

Sometimes

Often

Always

7) Over the past two (2) weeks, how often have you felt paranoid or fearful you are in danger?

Never

Sometimes

Often

Always

8) How does your pet helps with your emotional well-being?

Calms anxiety

Stress reducer

Loneliness & isolation

Comment box:

Add details:

Consent to Treatment and Communication

Iconsent to receive mental health treatment from [Provider’s Name/Organization]. I understand that: CertymyESA will conduct Assessment and review of recommended interventions as needed. My participation is voluntary, and I may withdraw consent at any time. My personal information will be kept confidential, except as required by law. Telehealth sessions (if applicable) follow the same privacy and security standards as in-person visits. I have the right to ask questions and discuss any concerns regarding my treatment.

I acknowledge that I have read, understood, and agree to the terms outlined above.

Signaure

Clear

Date:

Support

Get your official ESA/PSD letter for emotional support today.

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