Get Your ESA Letter

1How often do you experience emotional distress, anxiety, or depression?*

2Which of the following do you currently experience? (Select all that apply)*

3Have you experienced a major life change or transition that is impacting your mental health or causing stress?*

e.g., moving, divorce, job loss, illness, grief, relationship changes

4How long have you been experiencing these challenges?*

5How often do your symptoms interfere with your daily life, work, or responsibilities?*

6How often do you experience difficulty sleeping or disrupted sleep?*

7How often does your mental health cause you to withdraw from social activities or relationships?*

8Are you currently taking any prescribed medication for a mental health condition?*

9Have you previously received a mental health diagnosis from a licensed professional?*

10Are you currently receiving mental health treatment or therapy?*

11In your own words, please describe your symptoms and what you are going through.*

This helps your provider better understand your experience and how your ESA supports your well-being. Please share as much as you feel comfortable with.

12What type of housing do you currently live in?*