Psychiatric Support Animal Questionnaire

Your answers are confidential and help our professionals determine your eligibility.

Confidential Screening

Your answers are confidential and used to help our licensed professionals and qualification system determine your eligibility. Please answer truthfully.

What type of animal do you have? *

Dog Cat

Emotional and Psychiatric Symptoms

Over the past two weeks, how often have you experienced the following?

How often have you experienced intense anxiety, panic, or fear without a clear trigger? *

Never Rarely Sometimes Often Always

How often have you experienced flashbacks, intrusive memories, or distressing nightmares? *

Never Rarely Sometimes Often Always

How often have you felt detached from reality or disconnected from your surroundings? *

Never Rarely Sometimes Often Always

How often have you experienced severe mood swings, emotional crashes, or loss of emotional control? *

Never Rarely Sometimes Often Always

How often have you felt unsafe, disoriented, or unable to cope in everyday situations? *

Never Rarely Sometimes Often Always

Functional Impact on Daily Life

Tell us how these experiences affect your ability to function.

Do these symptoms substantially interfere with your ability to work, study, or complete daily routines? *

Yes No

Do you experience episodes (panic, dissociation, emotional breakdowns) that interrupt normal activities? *

Yes No

Do your symptoms make it difficult to leave home, travel, or be in public environments independently? *

Yes No

Animal Task-Based Psychiatric Assistance

These questions help us determine whether your animal performs or could perform psychiatric support tasks.

Does your animal perform trained tasks to assist with your psychiatric disability (or is it currently in training to do so)? *

Yes No Currently In Training

Does your animal help interrupt or reduce panic attacks, flashbacks, or dissociative episodes? *

Yes No

Does your animal perform grounding, alerting, or protective behaviors during psychiatric episodes? *

Yes No

Has your animal demonstrated the ability to perform these tasks reliably in public or real-world settings? *

Never Rarely Sometimes Often Always

Back

Screening Passed

You're Eligible!

Congratulations — you have met the requirements and are eligible to receive your PSA Doctor Letter.

What Happens Next

1 Complete your registration details on the next page.

2 Finalize your payment at checkout.

3 A licensed clinician will review your submission.

4 Upon approval, your letter will be delivered via email.

Continue to Registration

Not Eligible at This Time

Based on your responses, you do not currently meet the requirements for this letter. You can see other choices below.

See Other Choices