ESA Accommodation Verification Form

This form is to be filled out by a licensed health practitioner on behalf of their client who is requesting an emotional support animal accommodation at Northland College.

The form below can be completed and submitted online, or downloaded here and returned to the College by mail.

For questions regarding completion of this form, contact the Office of Accommodations at (715) 682-1387.
Student Name*
First Last
Proposed ESA
Type of animal*
Name of animal*
Age of animal*
Student Information
The above-named student has indicated that you are the (physician, psychiatrist, social worker, mental health worker) who has suggested that having an ESA in the residence hall will be helpful in alleviating one or more of the identified symptoms or effects of the student’s disability. So that we may better evaluate the request for this accommodation, please answer the following questions:
What is the nature of the student’s mental health impairment (how is the student substantially limited?)*
Does the student require ongoing treatment? If yes, please elaborate.*
How long have you been working with the student regarding this mental health diagnosis?*
Information About the Proposed ESA
Is this an animal 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?*
What symptoms will be reduced by having the ESA?*
Is there evidence that an ESA has helped this student in the past or currently?
Importance of ESA to Student’s Well-Being
In your opinion, how important is it for the student’s well-being that the ESA be in residence on campus? What consequences, in terms of disability symptomology, may result if the accommodation is not approved?*
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?*
Provider Information
Certification
- I certify, by my name below, that I conducted or formally supervised and co-signed the diagnostic assessment of the student named above.
Name
First Last
Title
Date*
MM slash DD slash YYYY
State of License*
License Number
Email*
Phone*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Thank you for taking the time to complete this form. If we need additional information, we may contact you at a later date. We recognize that having an ESA in the residence hall can be a real benefit for someone with a significant mental health disorder, but the practical limitations of our housing arrangements make it necessary to carefully consider the impact of the request for an ESA on both the student and the campus community. All documentation submitted to the Office of Accommodations is confidential. A copy of this form will be emailed to you for your records.
Be certain to click the SUBMIT button. You will receive an email confirmation soon after submitting the form. If you do not receive an email confirmation, it means your form did not go through and you need to resubmit.

Proposed ESA

Student Information

Information About the Proposed ESA

Importance of ESA to Student’s Well-Being

Provider Information