THE APPLICATION ESA & PSD INTAKE FORM

Pet Therapy Intake Form

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

Full name

Date or Birth

Phone

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

YES

Animal’s name

Gender

Breed and Weight

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.

Please verify that this animal presents no health risk from any zoonotic diseases. (If yes, please enter your initials)

Include your pet's Veterinarian’s Name

Include a picture of your animal.

Choose File

Reason for the ESA request? Symptoms? Previous or current diagnoses, treatment, medications etc.

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

Limited ability to concentrate or focus on activities/tasks

Difficulty relating appropriately with others

Responds inappropriately to social situations

Limitations in organization and planning

Limited or no stamina to perform activities

Limited stress, frustration, or anger tolerance

Does your animal provide emotional support? Which symptoms does your animal alleviates? List between two – three-four symptoms

List your treating health provider? Are you been treated at this time for these symptoms or condition? if yes, by whom? and when was your most recent appointment with this provider? Medication or Therapy or Monitoring?

Health History? General Health? Satisfactory / Good / Poor? ...explain in detail.

Support system? who do live with? married, single, divorced, separated, widow? children? plus are you working at this time, what do you do for living; school? Any other pertinent information you may want to share.

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

Date (Intake Form)

Your Signature

SUBMIT