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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.
  • Proposed ESA

  • 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:
  • Information About the Proposed ESA

  • Importance of ESA to Student’s Well-Being

  • Provider Information

  • MM slash DD slash YYYY
  • 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.

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Ashland, WI 54806
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https://my.northland.edu/campus-life/student-wellness/accommodations/esa-verification