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Emotional Support Animal
(ESA) Assessments

Please fill out the following form to help us understand your overall wellness condition.

How were you refered to Calm Mind Behaivioral Counseling
Rate quality of relationship
PoorFairGoodVery goodExcellent
Do you have children
Childrens develpmental level

Health Information

Rate your physical health.
PoorFairGoodVery goodExcellent
Please select any chronic heath condition
Do you have dificulty sleeping?
Please describe any sleep difficulties
Do you exercise routinely?
Please describe exercise
Do you have any problems or concerns about your appetite or food intake?
Please describe Appetite
Have you experianced significant weight change in the past 2 months?
Please describe Weight
Do you regularly drink alcohol?
Please describe Alcohol
Do you engage in recreational drug use?
Please describe Drugs

Psychiatric Information

Please describe the specific issues which an ESA will provide support. Sellect all that apply.
Have you been in counseling before?
Have you ever been diagnosed with an mental illness.
Are you or have you ever been prescribed psychiatric medications?
Do you currently own a pet.
What type of animal are you considering for an ESA?
Are you aware of the legal and ethical responsibilities that come with obtaining an ESA letter? These may include restrictions on where you can take your ESA and potential implications for your personal and professional life.
Are you aware that having an ESA letter may require sharing your mental health diagnosis and treatment history with housing providers and airlines, and that this information may become part of your clinical records?
I understand that providing false or misleading information in this assessment can have legal and ethical consequences. I affirm that my responses are accurate and truthful to the best of my knowledge.

Thanks for submitting!
Schedule an ESA Consultation

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