Esa Provider Request For Information Form - Lynchburg College (Page 2 of 3) in pdf

Esa Provider Request For Information Form - Lynchburg College Page 2

4. How long have you been working with the student regarding this mental health diagnosis?

Information About the Proposed ESA

1. Is this an animal that you specifically prescribed as part of treatment for the student, or is it a pet

that you believe will have a beneficial effect for the student while in residence on campus?

2. Please describe specific symptoms which may be reduced by having an ESA.

3. Is there evidence that an ESA has helped this student in the past or currently? If so, please explain.

Importance of ESA to Student’s Well-Being

1. In your opinion, how important is it for the student’s well-being that the ESA be in residence on

campus? What consequences, in terms of disability symptomology, may result if the

accommodation is not approved?

2. Have you discussed the responsibilities associated with properly caring for an animal while

engaged in typical college activities and residing in campus housing? Do you believe those

responsibilities might exacerbate the student’s symptoms in any way? (If you have not had this

conversation with the student, we will discuss with the student at a later date.)

Thank you for taking the time to complete this form. If the Disability Services Coordinator needs

additional information, the College may contact you at a later date. The College recognizes that having an

Julia R. Timmons, Disability Services Coordinator

Eff. May 2016

Esa Provider Request For Information Form - Lynchburg College Page 2