Fillable Emotional Support Animal Information Form Student By signing (Texas State University)

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Emotional Support Animal Information Form Student By signing (Texas State University)

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The Emotional Support Animal Information Form Student By signing (Texas State University) form is 2 pages long and contains:

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  • 6 check-boxes
  • 21 other fields

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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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5. Date of last contact with the student regarding this mental health diagnosis:
Month/Day/Year
Information About the Proposed ESA
Please note that there are some restrictions on the kind of animal that can be approved for the residence hall; it is
possible the student may be approved for an ESA, based on the information you provide here, but may not be
allowed to bring the specific animal named.
1. Is the animal one 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. What specific symptoms will be reduced by having an ESA, and how will those symptoms be mitigated by the
presence of the ESA?
3. Is there evidence that an ESA has helped this student in the past or currently? Yes No
Importance of ESA to Student’s Well-Being
1. In your opinion, how important is it for the student’s well-being that an ESA be in residence on campus? What
consequences, in terms of disability symptomology, may result if the accommodation is not approved?
2. This student was provided with a copy of the rules and restrictions surrounding the presence of an animal in
residence in the University housing. Has the student shared those restrictions with you? Yes No
3. 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.
Mental Health Care Provider – By signing below (print/type), you are confirming that you are the qualified
healthcare professional who is providing the information above.
Name: Type of License & License #:
Address: Phone:
Fax:
Email Address:
Signature: Date:
Please fax the completed form to the Office of Disability Services at 512.245.3452.
If we need additional information, we may contact you at a later date. The student has signed this form (above)
indicating written permission to share additional information with us in support of the request. If you have any
questions, feel free to contact our office. Thank you.
2
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Emotional Support Animal Information Form Student By signing (Texas State University)

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Completed 25 January 2022

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