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

Esa Provider Request For Information Form - Lynchburg College Page 3

ESA in the residence hall 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.

Please provide contact information, sign and date this questionnaire (below), and return it to:

Julia Timmons, Disability Services Coordinator

Academic Achievement Center

Lynchburg College

1501 Lakeside Drive

Lynchburg, VA 24501

Fax: 434-544-8808

Email: timmons.j@lynchburg.edu

Contact information

Name: ______________________________________________

Address: ___________________________________________

_______________________________________________________

FAX and/or Email address: ___________________________________________

Telephone #: ___________________________

Professional Signature: ___________________________________________

License #: ___________________________________________

Date: ___________________________________________

Julia R. Timmons, Disability Services Coordinator

Eff. May 2016

Esa Provider Request For Information Form - Lynchburg College Page 3