Esa Provider Request For Information Form - Lynchburg College printable pdf download

Esa Provider Request For Information Form - Lynchburg College

Emotional Support Animal

Provider Request for Information Form

Student’s Name:

__________________________

Proposed ESA Information:

Species:

__________________________

ESA Name:

___________________________

Breed:

__________________________

Age of animal: __________________________

Gender of animal: ______________________

Is the animal Spayed or Neutered: Yes

The above-named student has indicated that you are the (physician, psychiatrist, social worker, mental

health worker) who has suggested that having an Emotional Support Animal (ESA) in the residence hall

will be helpful in alleviating one or more of the identified symptoms or 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 us 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.”)

1. What is the nature of the student’s mental health impairment? Please include a DSM-IV or V

diagnosis (specific disability) and pertinent background information related to the disability.

2. How is the student substantially limited by this disability such that an ESA would be necessary for

this student to have full benefit or enjoyment of housing on a college campus?

3. Does the student require ongoing treatment for this diagnosis and if so how is that treatment

being provided?

Julia R. Timmons, Disability Services Coordinator

Eff. May 2016

Esa Provider Request For Information Form - Lynchburg College