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Welcome to the first step of qualifying for an emotional support animal! 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
First Name (Legal Name)*
Last Name*
Confirm Age*
- I confirm that I am 18 years of age or older
Date of birth

DD
MM
YYYY

Must be an adult 18+
Email*
Enter Email Confirm Email
Enter your phone number to expedite the process
Gender
- Male
- Female
Which state are you currently a resident of (So we can connect you to a therapist in your state)?*
Preferred Emotional Support Pet*
- Dog
- Cat
If you select OTHER please fill in the specific type of animal above.
Number of animals*
At this time, unfortunately, we are unable to assist you if you have more than 3 Emotional Support Animals.
If you are experiencing technical difficulties, please submit your ESA questionnaire from another browser.

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Confirmation

Please review your information to make sure everything is as accurate as possible.
I hereby certify that information I have provided is accurate and correct to the best of my knowledge.
Signature*
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.

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Confirmation