2025 Confidential Evaluation Assessment Form for a Psychiatic Service Dog or an Emotional Support Animal

Next Generation Psychology

www.ESApros.com

Email-ESA@ESAevaluation.com

P-760-485-6784

Registration Information

Is this a Renewal ESA evaluation? No Yes Date of last ESA Evaluation
Legal Name (Name as on Passport)
Female Male
Status: Married Single Widowed Domestic Partner Divorced

Spouse Name or SO or DP Name: N/A

Date of Birth: Age:

Phone Number you prefer us to call you on for the evaluation:
Additional Phone Number:

ok to text

Email Address:Home Address Unit/Condo/Apartment # *Include if applicable*

City

State Zip Code

Employer/Occupation

Emergency Contact Name and Number

Contacts Number

Emergency Contacts Relationship to you?

How did you hear about us?

Friend Ad Internet Search FB Other

Confidential History Information

Explain what has happened this year that has affected you significantly?

Check all Issues affecting your daily functioning, such as Work, Emotional, Social or Daily Activities:

Emotional:

Sad Overwhelmed    Low Motivation    Agitation    Withdrawing    Anxious
Angry    Lonely    Returning from or Deployment of you or a family member
Have you Experienced:  A Death or Loss this year (whom)   A move this year   Divorce or break up this year    Explain any Legal issues affecting you:

Work Interference:

Poor Concentration Low Productivity Missing work Financial Issues Work Stress Underperforming Learning issues Limited ability to speak in front of people
Toxic work environment Excessive Work travel Poor Focus or attention

Daily Functioning:

Weight Gain/Loss   Sleep problems Energy issues   Poor Eye Sight   Walking/Falling
Chewing Issues   Hearing   Memory Issues
Major Medical Issues: Explain

Social Functioning:

Family Issues Avoid Social Situations Few friends Test Anxiety Avoid going to functions or visits if you can't bring your animal

Do you Experience:

Fear of Flying Separation Anxiety Claustrophobia Avoid enclosed spaces Attention Deficit OCD Avoid elevators Avoid Crowds of People Anxiety Attacks RE-Experiencing prior abuse

Describe Your Animal(s):

Name Breed Weight Height

Which Daily Functioning does your animal help with?

Check all that apply:
Sleep better Helps to interact with others easier Better concentration at work or home Lowers Anxiety at home or work Take less meds Motivates to exercise

How will you use of the ESA letter?

Housing Other Explain:

Do you currently have Suicidal Thoughts?  No   If Yes Call or text NOW to the Suicide Hotline 800-273-8255 or 988
Have you had any psychological Hospitalizations?  No
If yes Dates and any Recommendations:

What type of Counseling have you had: Marriage Individual CBT When None

Family History of Psychological diagnosis?

What diagnosis? Depression Anxiety Bipolar Schizophrenia Other NONE Who in the family has this diagnosis

Past Psychological Diagnosis given you:

Current Medication w/doses

Have you been treated in the past for alcohol or drugs No

When were you treated for Alcohol or Drugs? Explain:

Do you have a history of verbal, emotional or sexual abuse?

Explain what type or abuse, when and by whom.

Personal History

Your education level (Degrees)

Military Branch/Years/Discharge

Description of your relationship with your Spouse or Significant other

With your parents

Childrens name and ages

Any living at home

Click here that: I understand and agree to a Confidential video chat session for an Emotional Support Animal (ESA) or Psychiatric Service Dog (PSD) evaluation or continue sessions, if choosen. We are unable to guarantee a confidential video chat, even using HIPPA compliant video chat or phone line if wireless technology is used. A Psychological diagnosis will be given and discussed with you, or a diagnosis given to your child and discussed with you, if a minot. The diagnosis is confidential and will not be put on the ESA or PSD letter or shared in any way without your written permission. After the ESA/PSD evaluation you will receive your letter by email or mail if specified. There are other treatment modalities or medications for a Psychological diagnosis other than an Emotional Support Animal (ESA) or Psychiatric Service Dog(PSD) Evaluation. You can call us for our full range of treatment options or recommendations for further treatment beyond the ESA evaluation. These are privately paid for check your therapist rates. Our average therapy sessions are 9. Ask your Therapist for their rates and availability. You can find treatment providers 1800 number on the back of your insurance card. There are always benefits and risks to treatment or lack of treatment. This is an Evaluation first, and recommendations made in the evaluation to have your animal as treatment for your psychological condition and it is your responsibility to follow thru for the best results. We are not crisis interventionalist. If you are having suicidal thoughts or want to hurt yourself in anyway, you can call 1800-273-8255 or 988 for immediate help or go to your closest ER. We have a duty to warn others and to keep you and others safe from harm. We abide by the laws and ethical principals that govern privilege and confidentiality. We will not disclose to anyone anything you tell us, without a written signed release of information. There are exceptions to this standard; If you tell one of our therapists that you want to harm yourself or an identifiable victim, we have a duty to warn the potential victim and the appropriate officials to keep that person and yourself safe. We are legally required to report ongoing child, elder or a disabled persons abuse. We have staff that may see your confidential information to make appointments or for other reasons, but all your information will be kept confidential. We use encrypted email and secure transmission, as much as feasibly possible, but there could be breeches at times, I will not hold Next Generation Psychology or its therapist liable. Arbitration only if a disrupt arises. I accept that I can be charged a $25 rescheduling fee for a missed appointment. Or charged the full fee for a missed second appointment. Any additional forms requested are charged separately. Housing accommodation forms or verification of letter require another session and a release of information completed with an additional fee of $112. No refunds if the ESA forms are received and processed.

I agree that I received and read the Notice of Privacy <-click here to review

Once we receive your completed Assessment form we will call you to schedule your ESA evaluation or call us with questions 760-485-6784

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