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Basic Information :

For this section, we need some basic information regarding your prescription

Yes

No

   

Male

Female

   

Travel

Housing

Both

 

Yes

No

   

Personality Overview :

These quick questions are here to evaluate where your pet will best fit your needs as far as emotional capabilities, anxiety management and overall personality.

During the past TWO (2) WEEKS,
how much (or how often) have you been bothered by the following problems?
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. 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

Symptons Breakdown :

In this section, we evaluate your symptons

In the past SEVEN (7) DAYS.... Never Rarely Sometimes Often Always
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

Symptons (Continued) :

This is the final section of your evaluation

Question 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.
Question 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.
I feel extremely self-confident all of the time.
Question 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.
Question 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.
Question 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.
Question 6: 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.

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Confirmation :

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.
 

Evaluating Qualifications :

 

Evaluating the information provided to see if you qualify as a good candidate for an emotional support pet...