10.Feeling that your illnesses are not being taken seriously enough?
11. Thoughts of actually hurting yourself?
12. Hearing things other people couldn't hear, such as voices even when no one was around?
13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
14. Problems with sleep that affected your sleep quality over all?
15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?
16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?
17. Feeling driven to perform certain behaviors or mental acts over and over again?
18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
19. Not knowing who you really are or what you want out of life?
20. Not feeling close to other people or enjoying your relationships with them?
21. Drinking at least 4 drinks of any kind of alcohol in a single day?
22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
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)]?
In this section, we evaluate your symptons
1. I was irritated more than people knew.
2. I felt angry.
3. I felt like I was ready to explode.
4. I was grouchy.
5. I felt annoyed.
This is the final section of your evaluation
Question 1: Describe your happiness.
Question 2: Describe your confidence level
Question 3:Describe your sleeping patterns
Question 4: Describe your social skills
Question 5: Describe your activity levels:
Question 6: For Travel Letters - How will your pet be traveling with you?
Question 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 esacert.com 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 esacert.com, and I consent for esacert.com 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.
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