Online Pet Evaluation Javascript is disabled Javascript is disabled on your browser. Please enable it in order to use this form. Loading Registration Pre-Qualification Question Form No. AMP210111-1R0501 Patient Evaluation Questions Form No. AMP210121-1R0517 Payment First Name Last Name Email Address Phone Address Title Recipient Address line one Address line two City State Zip Code 1. Have you ever experienced significant anxiety or panic attacks within the last 6 months? * Yes No 2. Have you ever experienced signs and symptoms of depression within the last 6 months?* Yes No 3. Are you currently experiencing significant stress and/or difficulties adjusting to a major life change?* Yes No 4. Is stress or mood impacting your social, occupational, or educational performance or ability to engage in these activities?* Yes No 5. Have you experienced a major life change in the last 6 months?* Yes No 6. Can you travel without your pet?* Yes No 7. Does you pet provide you strong emotional support?* Yes No 1. I am frequently sad and/or tearful. I cry without reason or at the slightest provocation in my daily life.* Not at all Slightly Moderately Often Highly Extremely 2. I am often overwhelmed and/or highly stressed given my current life circumstances and/or situation.* Not at all Slightly Moderately Often Highly Extremely 3. I find myself withdrawn and/or isolated because of overwhelming feelings.* Not at all Slightly Moderately Often Highly Extremely 4. It is difficult to engage my life as before, and my daily functioning is significantly impaired. I am missing my routine and find a lack of pleasure in activities that I once enjoyed due to my present circumstances.* Not at all Slightly Moderately Often Highly Extremely 5. I find it hard to control my daily worries and my mind quite often races ahead to the future or to events of the past.* Not at all Slightly Moderately Often Highly Extremely 6. In my daily life, I am finding myself very anxious, always on alert, easily startled, and irritable.* Not at all Slightly Moderately Often Highly Extremely 7. My stress and/or mental health condition causes difficulties to fall asleep, staying asleep, and often no sleep. * Not at all Slightly Moderately Often Highly Extremely 8. I have found myself tense, irritable, and have trouble concentrating on my daily life chores.* Not at all Slightly Moderately Often Highly Extremely 9. I drink or use drugs to cope with my mental health condition or with my current life stress situations.* Not at all Slightly Moderately Often Highly Extremely 10. In the past few weeks, have you wished you were dead, or have you felt that you or your family would be dead?* Write Here 11. I have seen a mental health professional in the last 12 months?* Write Here 12. In the past 12 months, I have been hospitalized for a mental health/psychiatric issue/s?* Write Here 13. Pet Breed, Pet's Name, and Weight Range (1 Pet Per Application)* Write Here 14. Please check any of the following conditions that you may have experienced in the past six (6) months? Decreased appetite Trouble concentrating Excessive sleep Isolation from others Fatigue/Low Energy Depressed mood Tearful or crying spells Anxiety Fear Hopelessness Waking up early Intense restlessness Excessive worry or concern Racing thoughts Difficulty being alone 15. Please write any other health conditions not covered above that you may have experienced or experiencing now? (Optional) Write Here Fees Amount WordPress › Error There has been a critical error on this website.Learn more about troubleshooting WordPress.