By inputting my signature, I confirm that to the best of knowledge, the information I have provided to esacertificate.org is accurate.
I also confirm that I understand my input information will be digitally sent to a licensed mental health professional, and am allowing it to be viewed by the therapist and anyone associated with the company who is involved in generating the ESA letter. I am allowing this therapist to assign treatment for the issues evaluated in the assessment by means of an ESA companion.
I also agree to the esacertificate.org terms and conditions, and I consent for esacertificate.org to contact me at the telephone number or email address that I provided.
If you are experiencing an emergency, you should seek treatment from an emergency service immediately.