2025 Psychiatric Service Dog

Confidential PSD and ESA Evaluation
Assessment Form
 

Next Generation Psychology 




Email-ESA@ESAevaluation.com

P-760-485-6784 

Website-ESAPros.com
 

Registration Information




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:
Additional Phone Number: 
 
 
Email Address:Home Address 
City   
 
State       Zip Code 
Employer/Occupation:​​​
Emergency Contact Name and Emergency Contact Number
Name:
Emergency Contacts Number 
Emergency Contacts Relationship to you?
 

 
How did you hear about us?  Friend     Internet Search      FB      
ESA     Other 
 
 
   Confidential History Information
 

What has happened in your life that has affected you significantly that you need a PSD?      Have you experienced: War, Stalked, Physically or Sexual abused, assaulted, a house break in, Bullied, severe weather events?   ( PLEASE EXPLAIN)



What Prior Psychiatic Diagnosis have you been given by a Doctor or Therpaist? Check all that Apply:   Don't know        PTSD       Anxiety       Depression    Bipolar       Social Anxiety   
 Panic Attacks     Agoraphobia    Specific Phobia(Flying,crowds, elevators)
Other Diagnosis:
What type of counseling have you had?  Marriage    Individual    CBT     None
Name of Doctor or Therapist: Doctor/Therapist phone number:
Doctor/Therapist email:

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

Without your PSD are these symptoms life limiting    

Emotional:     
 Sad/Overwhelmed   Low Motivation    Agitation        Withdrawing      Anxious 
 Angry     Lonely     A Death or Loss this year     A move this year       Divorce or break up this year       Legal issues affecting you 

Work Interference:

Poor Concentration    Low Productivity    Missing work     Financial Issues     
Work Stress    Limited ability to speak in front of people       Can't work  

​​​Daily Functioning:

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

Social Functioning:

Family Issues       Avoid Social Situations        Few friends        Test Anxiety         Avoid going to functions or visits     Avoids crowds of people     
Won't go to stores during rush hours     Problems Learning 
 
Do you Experience:
Fear of Flying     Separation Anxiety         Claustrophobia      Avoid enclosed spaces   OCD      Avoid Enclosed places     Avoid Crowds of People     Anxiety Attacks        
RE-Experiencing prior abuse       Overwhelmed in social situation 
Feel Unsafe without my Dog 
 
Describe Your Animal(s):
Name   Breed        Weight   
 
Name   Breed       Weight   

Which Daily Functioning does your animal help with?
Check all that apply: 
Sleep better    Better concentration at work or home         Go into crowds       
Walks/ Balances better        Socialize easier          Helps to get out of bed      
Go into public places        Nudges to move through a crowd  

How will you use your PSD?

Housing    Airlines    Going into Public places      Social Situations         School  
In crowds of people     Stores  
Other ways Explain:

Has your Animal been trained to help you with a Specific Task?

  No **If not, your Dog will need to be trained to Recognize, Respond and Reduce your psychological symptoms. (you can train it yourself) or have it trained to perform a task that helps you with symptoms of (Panic, depression, anxiety to fly, or be in crowds, or PTSD symptoms,etc.) to become a Psychiatric Service Dog (PSD) under the ADA.

  Yes-The dog has been trained or has organically learned and can accomplish a task to help with my Psychological symptoms and the dog can consistently helps with that specific tasks.

What task has your animal been trained to do or perform for you? Check all that apply;
 Helps Panic Attacks by applying pressure therapy
 Leads me out of an overwhelming situation from PTSD symptoms
 Brings me back from a dissociative state
 Move me to the edge of a crowd
 Helps within crowds 
 Nudges me to keep moving in social situations or crowds
 Helps me to get out of bed (licks, prods, barks, etc.)
 Gets between me and others to provide space
 Search a room before you enter
 Walk or balance better with my PSD at my side
 Other ways I will use my PSD 
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? 
​​​​​​If yes Dates:Recommendations: 


​​​​Family History of Psychological diagnosis?
Current Psychological Medication
Current Medication with doses 
Have you been treated in the past for alcohol or drugs   No   Yes 
When were you treated for Alcohol or Drugs?  Explain:
Family History of Psychological diagnosis   Anxiety  Depression   Bipolar 
Family Member with diagnosis: 
 
 
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 
​​​​​​

Tell us why you love having an ESA or a PSD?                                                                                                                                                                             
What is the best thing about having a PSD or an ESA?  
Why would you recommend getting a PSD or an ESA?  
Can we use your statements as testimonials (without your name)  Yes or No?    
Thank you for sharing how others could have more happiness in their world. JW.

 Click here that I agree: That I, the undersigned, hereby authorize the release of any psychological information necessary for the Mental Health Professional to evaluate me for a Psychiatric Service Dog (PSD). I accept that I can be charged full fee for appointments missed or cancel with less than 24-hour or an additional reschedule fee $50. No refunds if forms are received and processed. Any Additional forms requested are paid separately.  Housing forms or Housing verification additional session required $112. 

Any Add’l Therapy Sessions are availabe and recommended $112- 50 min. session. If I cancel an Individual session under 48 hrs. I can be charged for the session. 

​​​My signature below authorizes consent for a Confidential Video chat evaluation with 2 sessios that will result in a Psychological Diagnosis. I am unable to guarantee a confidential phone or texting line if wireless technology may be used in this process to schedule. There can be breaches with emailing, as it may not be encrypted or breaches in video chat or phone lines or electronic communication within programs.  But we will use HIPPA compliant video chat and secure email. There are always other treatment options such as medication and continuing psychotherapy. This is a Psychology evaluation for certification to have a PSD or an ESA and a session for recommendation and treatment, all included.  Or for additional Therapy sessions as an option. For other treatment options, look on the back of your insurance card for covered treatment providers. Please sign below to show that you have read all the documents, understand and agree with this Information and you are giving your Consent for a PSD evaluation, letter and sessions.  Click this Link>>Psychiatric Service Dog Evaluation and Treatment Philosophy

  I understand and agree that there is a group session option for the Psychiatric Service Dog (PSD) assessment second session, if I choose it.  I understand and agree that if I choose the group session option, to receive my PSD letter quicker, it is completely confidential, and you are committing to never sharing any information, whether, names, dates, or any of the content of any conversation that is shared.  You can be held personally liable for sharing or even acknowledging any information or the presence of anyone in the group. 

​​​​​ I agree that I received and read the Notice of Privacy <Click here to review

Once we receive your submitted Assessment form and payment we will call you to schedule your Video Chat PSD evaluation or call us with questions 760-485-6784
 

Sign your name with your mouse or finger then Click the Blue Button to Submit Form                     

Reset Signature