Emotional Support Animal Request Form
The Office of Disabilities Services evaluates requests for Emotional Support Animals (ESA) in
Black Hills State University owned housing. Approval requires that a student must have an
impairment that rises to the level of a disability in that it substantially limits one or more major
life activities, and Reliable Third-Party documentation stating the presence of an ESA will have
therapeutic benefit in alleviating one or more of the identified effects of the disability.
We accept documentation from a Reliable Third-Party who has personal knowledge of the student
through a professional relationship involving the provision of disability related services and who
are practicing within their ethical, legal, and professional obligations. To consider requests for
ESAs, documentation provided should include the following specific components. The absence of
one or more of these components should not be considered an automatic reason to disqualify the
• Format – Reliable Third-Party documentation should be typed/printed on official
letterhead, dated, and signed from a licensed and qualified professional (e.g. psychologists,
neuropsychologists, psychiatrists, clinical social workers, licensed counselors, psychiatric
nurse practitioners, and other relevantly trained healthcare professionals). It is also
recommended that the Reliable Third-Party provide contact information and any
professional licensing information. The documentation should include the student’s name.
• Contact Dates - date when provider first met with the student regarding the condition and
date of the last professional interaction with the student regarding the disabling condition.
• Substantial Limitations – a statement that the student has a physical or mental
impairment that substantially limits one or more major life activities and describes the
nature of the impairment (that is, how the student is substantially limited).
• Type of Animal – the type of animal that is requested and that it is necessary in university
• Necessity of ESA – a statement that the student needs the ESA because it provides
therapeutic emotional support to alleviate a symptom or effect of the disability of the
student and not merely as a pet. Please include specifically how the ESA mitigates the
symptoms or effects of a disability. Documentation should be specifically written to
provide support for an ESA in Black Hills State University Housing.
Please also note the following:
• Approved Emotional Support Animals must be under the control of their handler, at all times.
• Emotional Support Animals may be excluded if they pose a direct threat to the health and/or
safety of others. Emotional Support Animals that are not under the control of their
owner/guardian or who disrupt other guests may be considered a nuisance and will be asked to
leave. Nuisance behavior could be any of the following examples or any other behavior that
disrupts other guests, patrons, students, or employees. Examples: consistent non-stop barking,
growling, making noise, giving off offensive odors, chewing.
• Emotional Support Animals are subject to the Black Hills State University Policy 3.3: Service
Animals and Assistance Animals. Exotic or wild animals may not be allowed under the state,
county and city laws.
• The Emotional Support Animal handler must maintain sanitary conditions and clean any