Basic Information : Personality Overview : Symptons Breakdown : Symptons(Continued) : Confirmation :

What is your first name?

What is your last name?

What is your email address?

Enter your phone number

What is your date of birth?

Are you a current or former member of the armed forces?
Yes
No

What is your gender?
Male
Female

Which state are you currently a resident of?

Do you currently have an animal?
Yes
No

Approximate weight of animal? (ex: 25lbs)

What is your animals name?

What is your animals breed?


1. Little interest or pleasure in doing things?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

2. Feeling down, depressed, or hopeless?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

3. Feeling more irritated, grouchy, or angry than usual?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

4. Sleeping less than usual, but still have a lot of energy?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

5. Starting lots more projects than usual or doing more risky things than usual?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

6. Feeling nervous, anxious, frightened, worried, or on edge?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

7. Feeling panic or being frightened?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

8. Avoiding situations that make you anxious?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

10.Feeling that your illnesses are not being taken seriously enough?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

11. Thoughts of actually hurting yourself?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

12. Hearing things other people couldn't hear, such as voices even when no one was around?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

14. Problems with sleep that affected your sleep quality over all?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

17. Feeling driven to perform certain behaviors or mental acts over and over again?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

19. Not knowing who you really are or what you want out of life?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

20. Not feeling close to other people or enjoying your relationships with them?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

21. Drinking at least 4 drinks of any kind of alcohol in a single day?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day

23. Using any of the following medicines ON YOUR OWN, that is, without a doctor's prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]?
None - Not at all
Slight - Rare, less than a day or two
Mild - Several days
Moderate - More than half the days
Severe - Nearly every day


1. I was irritated more than people knew.
Never
Rarely
Sometimes
Often
Always

2. I felt angry.
Never
Rarely
Sometimes
Often
Always

3. I felt like I was ready to explode.
Never
Rarely
Sometimes
Often
Always

4. I was grouchy.
Never
Rarely
Sometimes
Often
Always

5. I felt annoyed.
Never
Rarely
Sometimes
Often
Always


1: Describe your happiness.
I do not feel happier or more cheerful than usual.
I occasionally feel happier or more cheerful than usual.
I often feel happier or more cheerful than usual.
I feel happier or more cheerful than usual most of the time.
I feel happier of more cheerful than usual all of the time.

2: Describe your confidence level.
I do not feel more self-confident than usual.
I occasionally feel more self-confident than usual.
I often feel more self-confident than usual.
I frequently feel more self-confident than usual.

3: Describe your sleeping patterns.
I do not need less sleep than usual.
I occasionally need less sleep than usual.
I often need less sleep than usual.
I frequently need less sleep than usual.
I can go all day and all night without any sleep and still not feel tired.

4: Describe your social skills.
I do not talk more than usual.
I occasionally talk more than usual.
I often talk more than usual.
I frequently talk more than usual.
I talk constantly and cannot be interrupted

5: Describe your activity levels.
I have not been more active (either socially, sexually, at work, home, or school) than usual.
I have occasionally been more active than usual.
I have often been more active than usual.
I have frequently been more active than usual.
I am constantly more active or on the go all the time.

6: For Travel Letters - How will your pet be traveling with you?
Travel carrier
On my lap
At my feet
My pet will not be traveling

7: Describe the reasons why you need an Emotional Support Animal AND what specific symptoms you are hoping to alleviate by having your ESA with you.


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.

By inputting my signature, I confirm that to the best of knowledge, the information I have provided to therapypet.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 therapypet.org terms and conditions, and I consent for therapypet.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.