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Expedite your certification by completing the Qualification Questionnaire below and continue to the payment page. Once your payment has been received, a Licensed Psychotherapist will immediately review your Questionnaire and e-mail you a Letter of Recommendation for an Emotional Support Animal (ESA) the same day. You can then fly with your dog as an ESA in the passenger cabin of a plane for a full year for free (no pet fees can legally be charged by airlines). Our service is limited to only those who qualify by approval by a Licensed Psychotherapist. All non-qualifying individuals will be fully refunded within 48 hours.

Disclaimer: This questionnaire is solely intended for the use of determining qualifications for traveling and/or residing with an emotional support animal (ESA). Many disabilities that qualify an individual for a service or support animal arise during childhood. If this questionnaire results in emotional distress, immediately seek medical treatment or emergency services by dialing 9-1-1. You must be at least 18 years old to complete this questionnaire. All information provided by patients is strictly confidential and we do not share any patient information or records with any third parties other than for processing purposes.

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Registration Info
Full Name
Email
Animal Name
Animal Species & Breed
1. Under the ADA, an individual with a disability is a person who: Has a physical or mental impairment that substantially limits one or more major life activities; Has a record of such an impairment; or Is regarded as having such an impairment. According to the above definition, do you think you have a disability?	-- Please Select -- Yes No Not Sure
2. If you answered yes to the above question has your disability been evaluated by a medical doctor, physician's assistant, psychiatrist, psychologist, social worker or other mental health or medical professional?	-- Please Select -- Yes No
3. When did your disability begin?	-- Please Select -- At childhood More than 5 years ago More than 6 months ago, but less than 5 years ago Less than six months
4. Does your disability affect your work life?	-- Please Select -- Yes No Not Sure
5. Does your disability affect your enjoyment of life?	-- Please Select -- Yes No
6. Does your disability affect your relationships with others?	-- Please Select -- Yes No
7. Does your disability limit your ability to perform daily tasks?	-- Please Select -- Yes No
8. Would you find it helpful to use a support animal to assist you in daily tasks?	-- Please Select -- Yes No
9. Would a support animal provide you with emotional and/or physical support?	-- Please Select -- Yes No
10. Would it be difficult for you to travel without your support animal?	-- Please Select -- Yes No
11. Which, if any, symptoms do you experience as a result of your disability?	-- Please Select -- Impulsivity Anxiety or Extreme Stress Symptoms of Depression Symptoms of Addiction Sensory Integration Dysfunction Mania Psychosis
I would also like to order a Letter of Prescription for the Fair Housing Act for an additional $75.00
(Please check) I acknowledge that I have answered the above questions completely, truthfully and without fraud or coercion, and that I have read both the Disclaimer and Privacy Policy.

Billing Info Full Name Company Phone Number Address Apt, Ste, Etc. City State -- Please Select -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah US Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip

Credit Card Info Cards Accepted Card Type -- Please Select -- American Express Discover Master Card Visa Card Number Expiration (mm/yy) / Card Verification Code ORDER TOTAL $99.99 Referral Code (if applicable) Comments By submitting your registration by clicking the "Submit Registration" button below, you acknowledge and accept the processing fee of $99.99.

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