Birthday*

Are you currently employed*

Have you been diagnosed with PTS(D), TBI or anxiety by a healthcare professional?*

Do you have an ESA or PSA letter?*

Have you been denied a ESA or Service animal from another organization?*

Is there anyone else living in your home?*

Do you have another animal in the home?*

Are you or anyone else in the home allergic to animal you are applying for?

Are you able to financially support, the care of an emotional support animal over the course of their lifetime? (We estimate the cost to be approximately $2000 per year).

What type of animal are you looking to adopt as an emotional support animal?*

Date*