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ESA Letter
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Name
*
First
Last
Email
*
Preferred contact method
Phone
Email
Patient Portal
Preferred language
English
Português
Español
Are you currently a Brain Health Psychiatry patient?
Yes
No
Not sure
Who is your current provider?
Karoline Mion
Eduward Grandes
Sabrina Chinea
Have you already discussed this ESA request with your provider?
Yes
No
I am not sure
Animal's name ?
*
Type of animal
Dog
Cat
Other
Breed
Age of the animal
of I language
What is the purpose of the requested letter?
Housing reasonable-accommodation request
Renewal or updated housing documentation
Other
Name of apartment community, landlord, or housing provider
Does the housing provider require an additional form?
Does the housing provider require an additional form?
Yes
No
Not sure
Requested completion date
Requested dates are not guaranteed. Processing time depends on provider review and whether additional information or forms are required.Do not enter diagnoses, detailed symptoms, therapy information, urgent concerns, or other sensitive medical information here.
I understand that ESA letters are subject to provider approval, and have a $125 fee if approved.
I authorize Brain Health Psychiatry to contact me about this request.
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