Emotional Support/Assistance Animal Request
Accessibility Resource Center

Student Request Form

Pease complete the following form with information about your request, treatment, and current needs.

Student Information
Student Name

First Name
Last Name
Email
Information Regarding Proposed ESA
Note: Animals must be toilet or litter trained, have all vaccinations up-to-date, and meet the minimum of 6 months of age.
Name of Animal
Type of Animal
Age of Animal
So that we may better evaluate the request for this accommodation, please answer the following questions and be specific.
How often do you meet with the Mental Health or Medical Provider who provided you with the letter of support? When was the last time you had an appointment?
How are you substantially limited by your mental health impairment?
How has an ESA alleviated the symptoms of your mental health impairment? What other treatments have you explored?
Have you considered the responsibilities associated with properly caring for an animal while being engaged in college activities and residing in campus housing?
What impact will living in campus housing have on your assistance animal?
Acknowledgment
Thank you for taking the time to complete this form.

We recognize having an ESA in the residence hall or family housing can be beneficial and Emotional Support Animals can perform an important role in the life of a person with mental or emotional conditions; however, the practical limitations of our housing arrangements make it necessary to carefully consider the impact of the request on both the student and the campus community.

When people who do not have a disability abuse the system by misrepresenting a pet as an ESA to obtain special accommodation, they undermine important accommodations for individuals with a legitimate need for this assistance.

Student Acknowledgment

By checking this box, I acknowledge that the information I have submitted is true and I have read the above statement. My request for an ESA/assistance animal is part of my therapeutic process.

Date
Month - Day - Year

Emotional Support/Assistance Animal Request Accessibility Resource Center

Student Request Form

Student Information

Information Regarding Proposed ESA

So that we may better evaluate the request for this accommodation, please answer the following questions and be specific.

Acknowledgment

Emotional Support/Assistance Animal Request
Accessibility Resource Center