Thank you for your order- Complete Your Evaluation!

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This consultation can be completed online in minutes from your smartphone or desktop. Your consultation will be evaluated and signed by a licensed Mental Health Professional.
Agreement*
- I have read,understand, and agree to all the Terms and Conditions and allow my assigned license Mental Health Provider to release my confidential medical records to United Service Dog, LLC and its agents.

Patient Information
Name*
First Middle Last
Please enter your name with proper capitalization. Improper capitalization may result in delayed processing of your order. Example:
Correct: John McDonald
X Incorrect: JOHN MCDONALD
X Incorrect: john mcdonald
DO NOT USE ALL CAPS
Confirm Name Spelling*
- I confirm my legal name is spelled and formatted properly
Where do you currently reside?*
If your state is not listed, we do not have any licensed therapists available to complete your order. Please contact support@unitedservicedog.com for further assistance
Important Notice:
Unfortunately we do not have a licensed mental health professional available in your state of residence. Please contact customer support at support@unitedservicedog.com for further assistance
Dog Name*

Please enter your dog's name with proper capitalization. Improper capitalization may result in delayed processing of your order, or showing incorrectly on your letter. Example:
Correct: Buddy
X Incorrect: BUDDY
X Incorrect: buddy
Dog Breed*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Phone*
Your Mental Health Professional may call you as part of this evaluation
Preferred Contact Time*
- 8am-10am
- 10am-Noon
- Noon-3pm
- 3pm-6pm
If your Mental Health Professional needs to contact you by phone to complete your evaluation, when is the best time to call? Please note we will try our best to coordinate with your preferred time, but if you are unable to answer, please call your Licensed Mental Health Profession back as soon as possible to reschedule to avoid delays in processing your evaluation
Date of Birth (Must be 18 or older)*
Sex*
Marital Status*
Occupation

If none, leave blank
Primary Doctor

If none, leave blank
Please list any previous or psychiatric conditions*
- Anxiety
- PTSD
- Insomnia
- Depression
- Obsessive-Compulsive disorder
- ADHD
- Anorexia
- Bulimia
- Adjustment Disorder
- Substance Abuse
Please list all medications you have recently or are currently taking

If none, leave blank

Name*
First Last
Email*
Phone*
How can we help you?*
- I need help placing an order
- I need help with an order I've already placed

Which of the following do you need help with?*
- Emotional Support Animal
- Service Animal
What is the Difference Between a Service Dog & Emotional Support Animal?
A service animal is trained to assist with a disability, whereas an emotional support animal provides therapeutic benefits through its presence alone. Service Animals are able to travel on planes and live in apartments without additional fees or restrictions. Service Animals are also allowed to accompany their handlers in public areas such as restaurants, stores and hotels. Emotional Support Animals are protected for housing, but are not generally permitted in restaurants and stores.

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How can we help you?*

**Due to the high volume of orders during the holiday season, additional processing time to complete your order may be needed. Your PDF copies are available for immediate download in your confirmation email and if you paid for tracking, your tracking number will be updated as soon as your package ships. Inquiries regarding order shipping status may not receive responses unless the delay exceeds 3 business days past your original shipping speed/ delivery date has passed. Once your package ships, the most up to date tracking can be found in your tracking email.**
Which of the following can we help you with?*
- Order Status
- I need to replace my documents
- I would like to add a second handler to my order
- I need to add a housing form
- I need to order an ESA Letter
- Issue with vest size
- I am missing items from my order
- I would like to add items to my order
- It's something else
Please Describe in Detail*

PREPAID ONLINE EVALUATION

Patient Information

DO NOT USE ALL CAPS

Important Notice:

Mental Health Questionnaire

Important Notice: Schedule Your Session

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