National Service Pets - Support Animal Intake

Step 1: Intake Form Step 2: Consent Form Step 3: Confirmation

Support Animal Intake

Share the details needed for a secure National Service Pets clinical review.

Client Information

Provide the contact and location details for your review file.

First Name

Last Name

Email Address

Phone Number

Create Password *

Confirm Password *

Full Name

State * Your state helps route the case to an appropriate licensed reviewer.

City *

Letter Type

Preferred Contact Method

Preferred Contact Time

Animal Information

Tell us about the animal or animals connected to your request.

Primary Pet (Required)

Primary Pet Name

Pet Type

Pet Weight (lbs)

Pet Breed

Pet Sex

Pet Photo

Second Pet (Optional)

Pet Name (2)

Pet Type (2)

Pet Weight (lbs) (2)

Pet Breed (2)

Pet Sex (2)

Pet Photo (2)

Third Pet (Optional)

Pet Name (3)

Pet Type (3)

Pet Weight (lbs) (3)

Pet Breed (3)

Pet Sex (3)

Pet Photo (3)

Screening Questions

Standardized questions help the reviewer understand current symptoms and support needs.

PHQ-9 Depression Assessment

Over the last 2 weeks, how often have these concerns affected you?

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself or that you are a failure

Trouble concentrating on things like reading or watching TV

Moving or speaking slowly, or being fidgety/restless

Thoughts that you would be better off dead or hurting yourself

GAD-7 Anxiety Assessment

Over the last 2 weeks, how often have these anxiety-related concerns affected you?

Feeling nervous, anxious, or on edge

Not being able to stop or control worrying

Worrying too much about different things

Trouble relaxing

Being so restless that it is hard to sit still

Becoming easily annoyed or irritable

Feeling afraid as if something awful might happen

Ready to Submit?

Review your answers, then continue to the consent form.

Your information is encrypted and HIPAA compliant