Emotional Support Animal Information Form
Student – By signing below (print/type), you consent to allowing your mental health care provider to share
any information relevant to your need for an Emotional Support Animal (ESA) as an accommodation, as
shown on this form, with personnel from the Office of Disability Services at Texas State University for the
next 60 days.
Name: Signature:
Date:
The above-named student has indicated that you are the mental health care provider who has suggested that
having an Emotional Support Animal (ESA) in the residence hall will have therapeutic benefit in alleviating one or
more of the identified symptoms or effects of the student’s mental health disability. Generally, we accept
documentation from providers in the state of Texas or the student’s home state who have personal knowledge of the
student, consistent with their professional obligations. Letters purchased from the internet for a set price rarely
provide the information necessary to support an ESA request.
The Federal Trade Commission (FTC) has been asked to investigate websites that purport to provide documentation
from a health care provider in support of requests for an ESA. The websites in question offer for sale documentation
that is not reliable for purposes of determining whether an individual has a disability or disability-related need for an
ESA because the website operators and health care professionals who consult with them lack the personal knowledge
that is necessary to make such determinations.
In order to better evaluate the request for this accommodation, we ask that you as the mental health care provider
please provide the following information.
Information About the ESA
ESA Name: Type of Animal: Age of Animal:
Information About the Student’s Disability
1. Please identify the diagnosis for this student and provide the corresponding code from the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-V).
2. Federal law defines a person with a disability as someone who has a physical or mental impairment that
substantially limits one or more major life activities. That suggests that a diagnosis (label) does not necessarily
equate with a disability (substantial limitation). How is the student substantially limited?
3. Does the student require ongoing treatment? Yes No
4. Date of first contact with the student regarding this mental health diagnosis:
Month/Day/Year
OFFICE OF DISABILITY SERVICES
601 University Drive | LBJ Student Center 5-5.1 | San Marcos, Texas
78666-4616
phone: 512.245.3451| fax: 512.245.3452 |
WWW.ODS.TXSTATE.EDU
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