EsA Letter

At Interception Counseling Services, LLC, we provide compassionate support through our letter writing service for emotional support animals. Our goal is to enhance your well-being and foster connections.

First name

Last name

Phone

Address

• Current mental health diagnosis(es), if known:

• Primary symptoms:

• How long have these symptoms been present?

• How often do these symptoms occur?

• How do these symptoms affect your work, school, relationships, sleep, or daily functioning?

• Are you currently participating in counseling?

• If yes, how long? Frequency?

• Are you currently taking psychiatric medication?

• If yes, please list:

• Animal's Name:

• Species/Breed:

• Age:

• How long have you owned your animal?

• Does the animal currently live with you?

• Is the animal current on veterinary care and vaccinations?

• How does your animal help your mental or emotional health?

• What symptoms improve when your animal is present?

• What happens when your animal is not with you?

• Why are you requesting an ESA letter at this time?

• Is this request for housing?

• Has your landlord or housing provider requested documentation?

• Are there pet fees or breed restrictions?

• Are you able to provide food, shelter, exercise, and veterinary care?

• Have you ever been accused of neglecting or harming an animal?

• If yes, please explain:

• What other coping strategies or treatments are you currently using?

• Is there anything else you would like your clinician to know?

Signature

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EsA Letter

Accepted Insurance Plans

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