Online Exam Form! Step 1 of 7 14% The exam below is a Psychological assessment evaluation and is comprised of 7 steps that are all required to be completed. It should take about 30 minutes to finish the exam. You must prepare yourself to complete the entire exam from start to finish, as there will be no way of saving your work and coming back to it later. Therefore, if you are not prepared to finish it in its entirety, please come back again when you have enough time to complete it. This exam is also MOBILE FRIENDLY so you will be able to use your phone if need be. Once you hit submit and complete your exam, please allow no longer than 2 business days for the mental health professional who reviews it to contact you with your results. If you are not approved, you will receive a same-day 100% refund. Part I: Personal InformationFirst Name* Last Name* Date of Birth* Street Address/Apt No* Phone Number* Email* City* *-- Select a State --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code* I confirm my address is correct* Confirm This address will be used for shipping of hard copy documents.Gender* Male Female How did you hear about us?*-- Make a Selection --CraigslistGoogleYahooBingFacebookTwitterReferralAnimal RescueOtherIf selected other, please specify: What's your current occupation? Please write your current occupation or if unemployed or a student please explain,* Marital Status* Married Single Divorced Widowed Preferred Emotional Support Pet* Dog Cat (Please specify if wanting more than one pet in the "other" box. Payment MUST be made for each pet, EX: 2 dogs) Please confirm the information above regarding spelling of your name, date of birth, email address, and gender are entered and spelled correctly. Any errors will cause complications with the approval process. PLEASE CONFIRM THE INFORMATION ABOVE REGARDING SPELLING OF YOUR NAME, DATE OF BIRTH, EMAIL ADDRESS, AND GENDER ARE ENTERED AND SPELLED CORRECTLY. ANY ERRORS WILL CAUSE COMPLICATIONS WITH THE APPROVAL PROCESS AND IF APPROVED, THERE WILL BE A $25 CHANGE/ EDIT FEE. Required* Agree Section 2: General and Mental Health1. Do you feel that you have a debilitating mental health condition that qualifies you to obtain an emotional support animal under U.S. law?* Yes No If you answered yes to the above question, please describe what debilitating emotional/mental health condition(s) you have below.2. Have you ever been formally diagnosed with a mental-health related condition by a medical professional? (Examples include: anxiety, depression, post-traumatic stress disorder, insomnia, bi-polar disorder, just to name a few.)* Yes No If you answered yes to the above question, please write below which mental health condition(s) you were diagnosed with. (Examples include: anxiety, depression, post-traumatic stress disorder, insomnia, bi-polar disorder, just to name a few.)3. Has there been a major life event in the last year that has caused you great psychological stress? (Examples include: divorce, a break-up, financial troubles, unemployment, or a death in the family)* Yes No If you answered yes to the above question, please list the major life event(s) below and how it has impacted you:4. Have you personally experienced any external physical symptoms over the last year? (Examples include: shortness of breath, sweating, trembling, crying, vomiting, etc..)* Yes No If you answered yes to the above question, please be as specific as possible in describing your symptoms and list the month and year that the symptoms began.5. Do you feel that your emotional/mood condition negatively impacts your ability to carry put your day-to-day activities such as: walking, sleeping, working, learning, concentrating, focusing, communicating, reading, or standing?* Yes No If you answered yes to the above question, please list below which daily activities you are unable to perform due to extreme stress or another emotional condition and how it has impacted your life. Section 3: General Medical History:1. Have you ever been diagnosed with a condition or illness not related to mental health?* Yes No If you answered yes to the above questions, please list below what you have been diagnosed with in the past.2. Are you currently taking any prescription medications, herbs, homeopathic or holistic treatments?* Yes No If you answered yes to the above question, please list ALL medications/treatments you are currently taking as well as dosage.3. Would you consider yourself to be in good physical health over the past 12 months?* Yes No If you answered No to the above question, please list which physical ailments you have endured over the last year. (Examples: cancer, broken bones, heart condition, stroke, just to name a few)4. Do you currently consume alcoholic beverages?* Yes No If you answered yes to the above question, please describe below how often and how much alcohol is consumed when drinking.5. Do you currently use illicit drugs?* Yes No If you answered yes to the above question, please describe which drug(s) is used and how often you use it. Section 4: Major Depression1. Do you feel that you derive little pleasure in doing routine activities anymore?* Yes No If you answered yes to the above question, please describe which routine activities are impacted by your depression.2. Do you feel depressed on a daily basis?* Yes No If you answered yes to the above question, please list below the month and year the symptoms first appeared.3. Are you having trouble falling or staying asleep, or sleeping too much?* Yes No If you answered yes to the above question, please describe when the symptoms started below and how these particular symptoms are impacting your life.4. Do feel overly tired throughout your day with little amounts of energy?* Yes No 5. Do you feel that you have a tendency to overeat or undereat?* Yes No If you answered yes to the above question, please describe below the nature in which you over or undereat and the date the symptoms first appeared.6. Do you typically feel bad about yourself / or that you are a failure / or have let yourself or your family down?* Yes No If you answered yes to the above question, please explain below how often this feeling occurs and which events or situations give rise to these feelings.7 .Do you have difficulty concentrating on things, such as reading the newspaper or watching television?* Yes No If you answered yes to the above question, please list when the symptoms first appeared.8. Have you ever thought that you would be better off dead or of harming yourself in some way?* Yes No If you answered yes to the above question, please list below the situation(s) or event(s) that first gave rise to these thoughts and the month and year that they first occured.9. Do you currently consider yourself to be suicidal at the present time? If so, do you have a plan to carry it out?* Yes No If you answered yes to the above question, please describe below the nature of your plan.10. Does your major depression negatively impact your school, work, family life, or ability to carry out a reasonably normal lifestyle?* Yes No If you answered yes to the above question, please describe in detail how it impacts your life below. Section 5: Generalized Anxiety & Panic Disorder1. Do you experience sudden episodes of intense and overwhelming fear that seem to come on for no apparent reason?* Yes No If you answered yes to the above question, do you experience any of the following symptoms during these episodes: racing heart, chest pain, difficulty breathing, choking sensation, lightheadedness, tingling or numbness? Please describe below which symptoms apply to you:2. Do you worry about something terrible happening to you, such as embarrassing yourself, having a heart attack or dying when having an episode of anxiety?* Yes No If you answered yes to the above question, please describe the event or situation that first gave rise to your anxiety episodes and list the month and year in which the symptoms first appeared.3. Do you worry about having future episodes of anxiety or panic?* Yes No If you answered yes to the above question, please describe below which symptoms begin to surface whenever you start to worry about future episodes of anxiety or panic. (Examples include: Heavy breathing, shortness of breath, feeling that you will have a heart attack, sweating, etc..)4. Do you worry about a number of events or activities (such as work, family life, or a school performance)?* Yes No If you answered yes to the above question, please describe the nature of this worry:5. Is it difficult to control the worry?* Yes No If you answered yes to the above question, please describe how you have been attempting to control your worries.6. Do you feel as though you have two or more of these symptoms? (Feeling restless or on edge, being easily fatigued, having difficulty concentrating, feeling irritable, muscle tension, having difficulty falling or staying asleep, or restless unsatisfying sleep?* Yes No If you answered yes to the above question, please list below which two or more symptoms from the previous question you have.7.Have you experienced or witnesses a frightening traumatic event either recently or in the past?* Yes No If you answered yes to the above question, please describe the nature of the event without going into too much detail.8. Do you feel that your overall anxiety negatively impacts your school, work, family life, or your ability to carry out a reasonably normal lifestyle?* Yes No If you answered yes to the above questions, please describe how this anxiety has impacted your life. Section 6: Post Traumatic Stress Disorder1. Have you experienced or witnessed an event in your past that was any or all of extremely scary, horrifying, assaulting, and/or life-threatening?* Yes No If you answered yes to the above question, please explain below the nature of the situation or event (s) and the month and year they occured.2. Do you have recurrent and distressing memories of the event, even when you try not to think about it?* Yes No If you answered yes to the above question, please describe below the symptoms you experience when you recall these traumautic events.3. Do you have recurrent dreams of all or parts of the trauma?* Yes No 4. Do you sometimes feel like you are experiencing some part, parts and/or all of the traumatic event over again?* Yes No If you answered yes to the above question, please describe below how often you experience these feelings and in which setting the feeling usually occurs. (Examples include: work, school, family life, etc)5. Do you sometimes find yourself feeling traumatized or very frightened about something and cannot associate any memories with the feeling?* Yes No If you answered yes to the above question, please describe below the month and year you first started losing your memory as it relates to your fright.6. Are you making efforts to avoid thoughts, feelings or talking about the trauma?* Yes No If you answered yes to the above question, please describe below what you typically do to avoid recalling the past traumatic event(s).7. Do you avoid certain places, people, events and/or situations because they trigger (or might trigger) thoughts of the trauma?* Yes No 8. Are you unable to recall important aspects of the trauma?* Yes No If you answered yes to the above question, please list the month and year in which you first experienced your inabilty to recall important aspects of the trauma.9. Do you feel detached or estranged from yourself and/or others?* Yes No If you answered yes to the above question, please describe below when you first began feeling this way.10. Are you experiencing any problems falling or staying asleep?* Yes No 11. Are you having trouble concentrating, being irritable or jumpy?* Yes No If you answered yes to the above question, please describe below which symptom(s) in the previous question you have and the month and year you first began noticing that these symptoms were becoming a problem.12. When you think about the future, do you get a sense that it will be shortened for some unknown reason?* Yes No If you answered yes to the above question, please list why you feel that the future will be shortened for some unknown reason. Section 7: SOCIAL PHOBIAS1.Do you have difficulty speaking in front of groups or a fear of talking to strangers in general?* Yes No 2.If you answered yes to the above question, please describe the difficulty as it relates to you below.3.Does the fear in the previous question cause you to have debilitating anxiety?* Yes No If you answered yes to the above question, please describe below the symptoms associated with your anxiety.4. Are you afraid of embarrassing yourself in public or in front of others?* Yes No If you answered yes to the above question, please explain below why you feel this way.5. Has your fear of embarrassing yourself in public caused you to avoid your daily responsibilities such as work, school, or any other public events?* Yes No If you answered yes above, please describe below what major life activities have been impacted by your social phobias? Examples include: Walking, talking, lifting, reading concentrating, communicating, sleeping, and/or writing)6. Are you afraid of flying on a commercial airliner?* Yes No 7. Do you get anxious and worried if you fly?* Yes No If you answered yes to the above question, please describe the nature of your anxiety and worry below.8. Do you avoid flying when possible?* Yes No 9. your past and/ or present life experiences, has had having an animal helped alleviate/ ameliorate your complaints, problems or issues, and is that the reason in which prompted you to submit this medical exam?* Yes No If you answered YES above, please explain further in detailChoose a Plan:* Compassion Plan - $199 (Covers 1 Pet Only) Care Plan - $159 (Covers 1 Pet Only) Travel Plan - $149 (Covers 1 Pet Only) Additional PetsSelect1 Additional Pet2 Additional PetsDo you have or want more than 1 pet as an ESA? Get a discount of ONLY $99 for each additional pet!Optional Same Day Service Same Day Rush Service Do you want or need this approval process expedited to ensure that you get your approval letter within 24 hours if you are approved? Get your submission to the top for a rush fee of ONLY $49.95!Total $ 0.00 Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name By checking agree below, I agree I will not be eligible for a refund for any reason unless the mental health professional does not approve me. Also I acknowledge after submission that the exam cannot be canceled during the review process. Required* BY CHECKING THIS BOX AND UNDER THE PENALTY OF PERJURY, I ACKNOWLEDGE THAT I HAVE ANSWERED THE QUESTIONS ON THIS QUESTIONNAIRE HONEST AND TRUTHFUL. * BY CHECKING THIS BOX I UNDERSTAND THAT I AM GIVING MY CONSENT FOR THE DOGTOR TO SUBMIT THIS QUESTIONNAIRE TO AN INDEPENDENT LICENSED MEDICAL PROFESSIONAL IN THEDOGTOR’s REFERRAL NETWORK TO REVIEW AND EVALUATE THIS QUESTIONNAIRE. * BY CHECKING THIS BOX I UNDERSTAND IF I AM APPROVED FOR AN EMOTIONAL SUPPORT ANIMAL(s), I WILL NOT BE ENTITLED TO ANY REFUND AMOUNT FOR ANY REASON. * Due to ESA travel laws being changed by the Department of Transportation, I understand that my ESA letter for TRAVEL may no longer be valid after January 3, 2021. However, I am willing to move forward with my ESA approval submission, and if approved, I will NOT ask for a refund. I trust The DOGtor will do whatever they can, if possible, to change whatever they need to accordingly so I will be able to travel with my furry family support companion in 2021 and beyond. Attention: You must submit payment in order for this medical exam to be evaluated.
