Student Emotional Support Animal Request Form

Name

First Name

Last Name

Salve ID#

Salve Email

Animal Information

Animal name

Animal Species and breed

Please explain the duration of your relationship with this animal

Most recent vaccinations

Veterinarian Information

Name, phone number and address

What is your diagnosis?

When was it diagnosed? By Whom? What tests/instruments were used?

Please describe the nature and severity of your disability

Please document your history of difficulty with public/communal housing

What measures/treatments have been tried prior to an ESA?

What identified symptoms of your diagnosis will be alleviated by the requested ESA?

In what ways will the requested ESA alleviate these symptoms?

How is the requested ESA necessary for you to use/access your living space?

Have you experienced or currently experience a benefit from this requested ESA?

As the ESA is a housing only accommodation (not permitted in common areas), are you able to properly care for an ESA while actively engaging in university life and activities?

What, if any, are the potential negative outcomes of having an ESA on campus?

Please list two people that will be able to care for the ESA in the event of an emergency:

#1-On campus Name and phone number #2-Off campus Name and phone number

If you have any documentation you would like disability services to have, please upload it below.

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Along with this form, please have your professional submit a REQUEST FOR CERTIFYING PROFESSIONAL’S DOCUMENTATION for an EMOTIONAL SUPPORT ANIMAL (ESA) as documentation of your condition. This form must completed by a licensed provider, with whom you are actively engaged with for treatment. The provider must not be employed by the University Counseling Center and cannot be a relative. The provider must be licensed in either RI or your home state. Documentation based on electronic or telephonic contact may be deemed insufficient to establish need. **Please note that letters purchased over the internet, based on limited contact between student and provider in a relationship begun for the sole purpose of obtaining ESA documentation, do not provide the information necessary to support the request for accommodation.

It is requested that this documentation be sent to The Office of Disability Services no later than 30 days prior to the Emotional Support Animal coming to campus.

Please submit the above form online and send supporting professional documentation to Student Accessibility Services no later than 30 days prior to the Emotional Support Animal coming to campus. A Certifying Professional’s Form is included here for convenience for documentation purposes but is not required. No animal is permitted on campus before it has been officially approved by the University.