Emotional Support Animal

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Provider Request for Information form

Name *

Proposed ESA Information:

Species

Name of ESA

Breed

Age of animal

Gender of animal

Is the Animal spayed/neutered?

The above-named student has indicated that you are the (physician, psychiatrist, social worker,and/or mental health worker) who has suggested having an Emotional Support Animal (ESA) incampus housing will be helpful in alleviating one or more of the identified effects of the student’s disability. So that we may better evaluate the request for this accommodation, please answer the following questions (complete information will better assist in the decision making process for the ESA Request):

Information about the Student’s Disability: (A person with a disability is defined as someone who has “a physical or mental impairment that substantially limits one or more major life activities”).

What is the nature of the student’s mental health impairment? Please include a DSM orICD diagnosis (specific disability).

How is the student substantially limited by this disability such that an ESA would benecessary for this student to have full benefit or enjoyment of housing on a college campus?

Does the student require active ongoing treatment for this diagnosis?

Information about the Proposed ESA

Is this an animal that you specifically prescribed as part of a written active treatment plan for the student?

Please describe specific symptoms which may be reduced by having an ESA. Is there evidence that an ESA has helped this student in the past or currently? If so, please explain.

Important of ESA to student’s well-being

In your opinion, how important is it for the student’s well-being that the ESA be inresidence on campus? What consequences, in terms of disability symptomology, may result if the accommodation is not approved?

Have you discussed the responsibilities associated with properly caring for an animal while engaged in typical college activities and residing in campus housing? Do youbelieve those responsibilities might exacerbate the student’s symptoms in any way?

Thank you for taking the time to complete this form. If the college needs additional information, the college may contact you at a later date. The college recognizes that having an ESA in campus housing can be a real benefit for someone with a significant mental health disorder, but the practical limitations of our housing arrangements make it necessary to carefully consider the impact of the request for an ESA on both the student and the campus community.

Name *

Organization name (if applicable)

Address

Address Line 1

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City

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Zip Code

Phone

Professional Type and License Number

Specialty

Signature *

Date / Time

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Emotional Support Animal