Request for Emotional Support Animal (ESA) Information Student’s Name: Banner ID: Type of Animal: Age of Animal: Date of Request: The above-named student has indicated that you are the (physician, psychiatrist, 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. Generally, we accept documentation from providers in the State of Missouri or the that we students’ home state. So may better evaluate the request for this accommodation, please answer the following questions: Student Disability Information (A Person with a disability is defined as someone who has or mental impairment that “a physical substantially limits one or more major life activities.”) What is the nature of the mental health impairment (that is, how is the student substantially student’s limited) Does the student require ongoing treatment? When did you first meet with the student regarding this mental health diagnosis?
Request for Emotional Support Animal (ESA) Information Student’s Name: Banner ID: Type of Animal: Age of Animal: Date of Request: The above-named student has indicated that you are the (physician, psychiatrist, 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. Generally, we accept documentation from providers in the State of Missouri or the students’ home state. So that we may better evaluate the request for this accommodation, please answer the following questions: Student Disability Information (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 (that is, how is the student substantially limited) Does the student require ongoing treatment? When did you first meet with the student regarding this mental health diagnosis?
esa-request-form.docx