Request appointment | At the Top Wellness LLC

At the Top Wellness LLC

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Reason for care

Select date & time

1 Appointment info

2 Prescreener

Reason for care

3 Contact information

Are you currently experiencing any mental health symptoms that interfere with your daily functioning? If so, please explain

Limited to 600 characters

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Attempted suicide in the past None of these apply

What is your reason for seeking an ESA or PSD evaluation?

I'm experiencing increased emotional or mental health symptoms I'm seeking housing accommodations I want to avoid pet fees or restrictions I need documentation for travel with my dog A previous letter expired A previous letter was rejected Other

Have you been diagnosed with a mental health condition by a licensed provider in the past? If yes, what was the diagnosis?

If no, put "N/A"

Have you experienced any of the following in the past 6 months?

Panic attacks (daytime or nocturnal) Sleep disturbances (insomnia or hypersomnia) Nightmares Flashbacks or dissociation Difficulty concentrating or focusing Intrusive thoughts or rumination Racing thoughts Persistent sadness or feelings of depression Isolation or social withdrawal Mood swings Difficulty managing emotions Substance use Self-harm behaviors or urges to hurt yourself Suicidal ideation Feelings of hopelessness Traumatic experience Restlessness None of these apply

If requesting a Psychiatric Service Dog (PSD) evaluation, is the dog trained to perform specific tasks related to your mental health condition?

Yes No In training N/A

If your dog is trained, please describe the trained tasks the dog performs

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

At the Top Wellness LLC

443.266.2585 |

Lake Worth

Main Location

Lake Worth, TX 76135-2607

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THE CLIENT PORTAL IS NOT TO BE USED FOR EMERGENCY SITUATIONS. IF YOU OR OTHERS ARE IN IMMEDIATE DANGER OR EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.