Required info

Please fill out all the information on the form before our consultation. Once we have the consultation, I will let you know if an ESA Letter is appropriate. This information is necessary to complete the letter.

ESA Letter - $150 (includes phone assessment)

Name

First Name

Last Name

Mental Health Diagnosis/Disability

Type of animal

Animal Breed

If you chose "other" please put the animal type and breed here.

Animal Weight

Animal Name

Support Provided

Please tell me more about how this animal provides you emotional support. Be as specific as possible.

Required info

Stacey Odell, LCSW