cute dog on welcome mat - ESA housing Dog

$189.00

 

TELEHEALTH INFORMED CONSENT

1. I understand that Pet Connect will provide administrative services to connect me with a licensed mental health professional via our online platform (“the LMHP”) to engage in a telehealth consultation. 2. I understand that telehealth technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit because I will not be in the same room as my provider. 3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing. 4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that the LMHP or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. 5. I understand that I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my personal and health information for in-person behavioral health services. Any information disclosed by me during my remote Telehealth, therefore, is generally confidential to the extent provided by law. 6. I understand and agree that this website is not an emergency-response or emergency-monitoring service and any person who is aware of an emergency situation or believes that a person may be at risk of injury or death or who may harm themselves or another person should immediately contact an appropriate emergency responder or dial “911” on a phone. Pet Connect is under no obligation to monitor or respond to communications made to, on or through this website and no user or person should rely on the website for medical or behavioral health advice or emergency services.
By signing this document, I acknowledge: I have read and understand the information provided above regarding teletherapy and all of my questions have been answered to my satisfaction. By clicking the “I AGREE” button at the bottom of this page, I am authorizing my assigned LMHP to assess my mental health via Telehealth and confirming my agreement and understanding of the statements above. I hereby give my informed consent and authorization for my LHMP to use Telehealth in my healthcare. I agree that a copy of this form may be treated as a signed original. BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.(Required)
Signature(Required)
By checking this, you are eSigning this form.

HIPAA AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

By clicking yes below, I authorize the licensed mental health professional and their employees and agents (collectively "Licensed Mental Health Professional") to give my medical information as described below to Pet Connect, LLC, and I authorize Pet Connect, LLC to provide medical information that I provide to Pet Connect, LLC to the licensed mental health professional. Description of information to be used or disclosed: the Emotional Support Animal (ESA) letter (the "Letter") provided by the Licensed Mental Health Professional, if one, and all records and medical or mental health information related to the Letter or related to the evaluation by the Licensed Mental Health Professional, including without limitation all information, opinions, diagnoses, assessments, notes, and documentation related to such assessment, and the Letter including any pre-screening or demographic information provided to Pet Connect, LLC by me. Purpose of the disclosure: I am requesting this information be disclosed for any purpose deemed necessary or advisable by Pet Connect, LLC. I understand that if my information is given out as allowed on this form, Pet Connect, LLC is not subject to federal privacy laws and may re-disclose my information. Therefore, those laws will not protect my information. This form expires 5 years after the date I provide authorization, by clicking yes below. I understand I have the right to withdraw permission for the release of my information. If I provide authorization to use or disclose information, I can revoke that authorization at any time. I understand the revocation must be made in writing to my Licensed Mental Health Professional at the address indicated on the Letter, and I am authorizing the release of my information voluntarily, and treatment, payment, or my eligibility for benefits will not be affected if I do not sign this authorization. I agree that a copy of this authorization may be treated as a signed document.
I authorize the use or disclosure of my individually identifiable health information as described above for the purpose listed(Required)
Signature(Required)
By checking this, you are eSigning this form.

Welcome to your first step in qualifying for an Emotional Support Animal. The following questions will help prepare your therapist for your consultation.

Pet Connect and the licensed mental health therapist you are connected with will keep your answers strictly confidential. Your privacy is important to us and we take it seriously. This form is solely used to inform the mental health therapist you are connected with to contact you. By completing this form and pressing submit, you understand that the maker and provider of this form does not take responsibility for any liability, loss, or risk incurred as a consequence, directly or indirectly, from the use and application of any of this material. The actions of an emotional support animal are the full responsibility of its owner.
Are you currently in California?(Required)
You must be in the state of California for your consultation.
Are you 18 or older?(Required)
If you are under 18, a guardian needs to be the point of contact with your mental health therapist.
I understand that I must meet the legal definition of disabled from a mental health disorder in order to qualify for an emotional support animal(Required)
Don't worry if you're not sure, you will be assessed by your therapist.
Do you already have a pet?(Required)
You can get an ESA letter for a current or future pet.
What kind of housing?(Required)
Our letters are Fair Housing Act compliant. The Fair Housing Act requires all landlords to accept compliant letters.
Do you have housing forms that need to be filled out in addition to your letter?(Required)
Don't worry, we will help you fill out any forms at no extra cost.

Mental Health Pre-Assessment Questionnaire

Pet Connect and the licensed mental health therapist you are connected with will keep your answers strictly confidential.
Have you experienced any major life events in the past 12 months that have caused you additional stress?(Required)
For Example: Divorce, financial stress, occupational stressors, or death.
Over the past two (2) weeks, how often have you had little interest or pleasure in doing things that you usually like to do?(Required)
Over the past two (2) weeks, how often have you felt sad or depressed?(Required)
Over the past two (2) weeks, how often have you felt more angry or more irritated than usual?(Required)
Over the past two (2) weeks, how often have you felt afraid or panicked?(Required)
Over the past two (2) weeks, how often have you had irregular sleep? (Sleeping too much or too little)(Required)
Over the past two (2) weeks, how often have you been acting impulsively? (Shopping too much, sudden use of drugs or alcohol, feeling like you’re “on top of the world”)(Required)
Over the past two (2) weeks, how often have you avoided situations that make you nervous?(Required)
Over the past two (2) weeks, how often have you heard things other people couldn’t hear and seen things other people couldn’t see?(Required)
Over the past two (2) weeks, how often have you felt paranoid or fearful you are in danger?(Required)
Over the past two (2) weeks, have you had thoughts of suicide?(Required)
IF YOU THINK YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM AND YOU SHOULD NOT PROCEED WITH CLINICAL SERVICES USING THIS PLATFORM. PET CONNECT AND OUR PROVIDERS DO NOT ATTEND TO MEDICAL EMERGENCIES. IF YOU ARE CONTEMPLATING SUICIDE, CALL 911 OR THE NATIONAL SUICIDE PREVENTION HOTLINE AT 1-800-273-TALK (8255). PLEASE CLICK ON THE MENTAL HEALTH RESOURCES LINK BELOW.
Mental Health Resources
Do you consent to be connected to a licensed mental health therapist for your telehealth consultation?(Required)
First Name (Legal Name)(Required)
MM slash DD slash YYYY
Gender(Required)
Responsibility(Required)
Consent(Required)
This field is for validation purposes and should be left unchanged.
SKU: 01 Category:

This package includes 2 telehealth appointments with your therapist. Your second appointment must be at least 30 days from your initial consultation per California AB 468 law.

Once payment is received, you will be provided a link via email to schedule your consultation with your therapist.

To complete your purchase, please complete the following forms.

 

Related products

Get in touch

1.800.858.6859

Get in touch

support@petconnectinc.com

Social Share

© 2023 Pet Connect, LLC • All Rights Reserved.