ESA Evaluation Pre-Screening

Please complete this brief pre-screening form to determine if you're eligible for an Emotional Support Animal (ESA) evaluation and housing-related documentation under the Fair Housing Act.

Only individuals who meet basic eligibility criteria will proceed to a full assessment. Submitting this form does not guarantee an evaluation or a letter.

Name

First Name

Last Name

Phone

(###)

###

####

Are you currently a client

Yes

Do you currently reside in Texas?

Are you seeking this letter for housing-related purposes only?

What type of animal do you currently have or plan to register?

How long have you had this animal (if applicable)?

Have you been diagnosed with a mental health condition?

How does this animal help alleviate symptoms or support your mental health?

Briefly describe any ways your condition currently interferes with your daily functioning.

I understand that completing this form is a screening process only. If I meet the initial criteria, I may be contacted for further evaluation and documentation.

Yes, I understand

ESA Evaluation Pre-Screening

Please complete this brief pre-screening form to determine if you're eligible for an Emotional Support Animal (ESA) evaluation and housing-related documentation under the Fair Housing Act.

Only individuals who meet basic eligibility criteria will proceed to a full assessment. Submitting this form does not guarantee an evaluation or a letter.

Wellwyn Health