Emotional Support Animal (ESA) Pre-Screening

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ESAs benefit individuals who struggle with mental and/or emotional disabilities by providing meaningful comfort and companionship.

Full Name *

Email Address *

Criterion A: Disability

You are aware that you are being pre-screened for a mental health-related disability assessment. *

Yes

You have a physical or mental impairment which substantially limits one or more major life activity. Major life activities can include, but are not limited to: caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working. *

Yes

No - You do not qualify for the ESA assessment

Not sure -or- I prefer not to disclose

You have a current diagnosis on-file which has moderate to severe symptomology and does not have a primary diagnosis of: Adjustment Disorder, V-Codes, and/or Unspecified Disorders. (If any of these diagnoses are listed as primary, they are exclusionary; however, they may be listed as secondary diagnoses.) *

Yes

No sure -or- I prefer not to disclose

You are not regarded as a juvenile offender or a sex offender, and you are not regarded as being a direct threat to others. (These are disability exclusions.) *

Yes

I prefer not to disclose - You do not qualify for the ESA assessment

Criterion B: Animal

Do you have a personal history of animal mistreatment or abuse? *

Yes - You do not qualify for the ESA assessment

You are aware that you, only, are being assessed and NOT the animal. *

Yes

Criterion C: Treatment Records (optional)

It is recommended that you obtain any treatment records or a treatment summary from your provider(s) to help confirm your diagnosis and functional impairment(s). Note: This is not required; however, it does help substantiate and possibly expedite the assessment process. *

I plan to obtain my treatment records.

I do not plan to obtain my treatment records -or- Not applicable.

Only basic information is covered here; many more aspects will be considered during the assessment process (a minimum of 3 sessions). ESA Letters and/or accommodations are not guaranteed. ESA Letters will only be issued when the assessment reveals that all criteria have been met. There is a chance that an ESA letter may not be indicated or issued to you. There is also a chance that accommodations may be denied even with an ESA Letter. Refunds for services rendered are not available regardless of whether an ESA letter is/is not issued and/or accommodations are/are not extended to you. *

I understand and I consent. I am requesting to schedule the ESA Assessment.

Thank you for completing the ESA Pre-Screening! Feel free to contact Shannon to schedule and/or if you have any questions or concerns.

*You may receive a follow-up email or text within 72 hours, Tuesday through Saturday.

By completing the ESA Pre-Screening form, you consent to being contacted by Soul Counseling with Shannon. *

I agree

I do not agree

If you prefer to be contacted via text, please enter your phone number. If not, you can leave this answer blank.

If you clicked any answer(s) that stated you do not qualify, feel free to explore helpful options for extenuating circumstances.

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