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Pet Therapy Intake Form

Please answer the following questions and return to Mental Health Provider for clinical review. Thank you!

Do you consent for this clinical review and give me your permission to review your request for an ESA or a PSD?

Please verify that your pet mentioned above has all current vaccinations as required, and that all of the above vaccinations will remain current through one year. Please verify that this animal has been treated and/or examined and found to be free of flea infestation. Please verify that the mentioned animal is in general good health and does not pose a direct threat to the health or safety of others.

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The following are functional impairments, please check the boxes that applies to you:

Thank you for completing and submitting your INTAKE Form. The MHP will review your information and follow up with you.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signatures is the legal equivalent  of your  manual signature on this application

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