Emotional Support Animal Request

Name
First Last
Date
MM slash DD slash YYYY
ID Number:
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact

In the event of an emergency, and the owner is unable to attend to the ESA, the following individual (not residing on the Seminary property) will take responsibility of the ESA:
Name
First Last
Date
MM slash DD slash YYYY
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Non-Residential Emergency Contact
In the event of an emergency, and the owner is unable to attend to the ESA, the following individual (not residing on the Seminary property) will take responsibility of the ESA:
Name
First Last
Date
MM slash DD slash YYYY
Email
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Family Member ESA

Separate tags with commas

In the event the request for an ESA is for a family member who will be residing in Seminary housing, please identify the family member and age of the family member.
Name
First Last
Age
Animal Being Requested
Breed
Name of Animal
Color of Animal
Age of Animal
Consent
I agree to the privacy policy.
By signing this form, I consent to allow my mental health care provider (or that of a family member) to share with authorized Asbury Theological Seminary personnel any information relevant to the need for an ESA as an accommodation, as shown on this form for the duration of residence at Asbury Theological Seminary.
Certified Professional Verification
Max. file size: 128 MB.

Emotional Support Animal (ESA) Request Form

When a student submits a request for the use of an Emotional Support Animal (ESA) in campus residences at Asbury Theological Seminary, the approval process requires specific diagnostic and therapeutic information from a licensed clinical professional who is directly responsible for the diagnosis and treatment of the disability. This information provides substantiation for the intentional use of an ESA as a therapeutic benefit of alleviating one or more of the identified symptoms or effects of the metal health disability of the student or family member.

An ESA is not a Service Animal and does not have public access. Unlike a Service Animal, an ESA does not assist a person with a disability with activities of daily living, nor does it accompany a person with a disability at all times. An ESA is incorporated into a treatment process to assist in alleviating the symptoms of that individual’s disability. This treatment occurs within the person’s residence and therefore may not be considered to have access to Seminary work environment or other public access.

Please note that the Disability Resource Center will NOT accept documentation completed by a member of the student’s family.
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 that support requests for an ESA. The websites in question offer documentation for sale that is not reliable for purposes of determining whether an individual has a disability or disability related need for an ESA, in that the website operators and consulting professionals lack the personal knowledge that is necessary to make such determinations.

To be completed by the student:

Name:___________________________________________ Date:_______________________

ID Number: _____________________________ Phone Number: _________________________

Address: ______________________________________________________________________

In the event of an emergency, and the owner is unable to attend to the ESA, the following individual (not residing on the Seminary property) will take responsibility of the ESA:

Name: __________________________________________ Date: ________________________

Email: ________________________________ Phone Number: __________________________

Address: ______________________________________________________________________

In the event the request for an ESA is for a family member who will be residing in Seminary housing, please identify the family member and age of the family member.

Name: ____________________________________________ Age: _______________________

Animal being requested: _____________________________ Breed: ______________________

Name of Animal: ________________ Color of Animal: ___________ Age of Animal:__________

Please submit vet records showing rabies vaccinations, as appropriate to species, with paperwork and a photo of the animal.

Student Signature: ________________________________________Date: ________________

By signing this form, I consent to allow my mental health care provider (or that of a family member) to share with authorized Asbury Theological Seminary personnel any information relevant to the need for an ESA as an accommodation, as shown on this form for the duration of residence at Asbury Theological Seminary.

To be completed by the certifying professional:

Certifying Professional Name: _____________________________________________________

Title: _________________________________________________________________________

License Number: _______________________________________________________________

Office/Agency Name: ____________________________________________________________

Office/Agency Address: __________________________________________________________

Office/Agency Phone: ___________________________________________________________

The above-named student has indicated that you are the mental health care provider who has suggested that using an Emotional Support Animal (ESA) for an individual living in the campus residence as a means for therapeutic benefit in alleviating one or more of the identified symptoms or effects of the mental health disability of the student or family member, so that the individual can more fully enjoy residential life at Asbury Theological Seminary.

Please note that there are some restrictions on the kind of animal that can be approved for the residence quarters. It is possible the student (or family member) may be approved for an ESA, based on the information you provide here, but may not be allowed to bring the specific animal named.

Does the student (or family member) who you have individually examined and treated have a mental impairment that substantially limits one or more major life activities?

_____NO

_____YES: Describe _____________________________________________________________

Identify the disability-related need for an ESA and explain how the animal alleviates one or more of the identified substantially limiting major life activities (thereby reducing the identified symptoms or effects of this individual’s existing disability).

__________________________________________________________________________

Does the student (or family member) require ongoing treatment?

_____ NO

_____ YES: Describe _____________________________________________________________

When did you first meet with the student (or family member) regarding this mental health diagnosis, and in what context (that is, was it a face-to-face meeting or a virtual interaction)?

__________________________________________________________________________

When did you last meet with this individual?_____________________________________

What type of animal is being requested?_________________________________________

Is the animal named here 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 individual while in residence on campus?

___________________________________________________________________________

What specific symptom will be reduced by having an ESA, and how will those symptoms be mitigated by the presence of the ESA?

__________________________________________________________________________

Is there evidence that an ESA has helped this individual in the past or currently? If so, please describe this.

___________________________________________________________________________

In your opinion, how important is it for the individual’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?

_________________________________________________________________________

The student was provided a copy of the rules and restrictions surrounding the presence of an animal in residence at Asbury Theological seminary. Has the student shared those restrictions with you?

_______ YES

_______ NO

Have you discussed the responsibilities associated with properly caring for an animal while engaged in residing in campus housing? Do you believe those responsibilities might exacerbate the individual’s symptoms in any way?

__________________________________________________________________________

Please attach the qualifying documentation that demonstrates the need for an Emotional Support Animal. Documentation Requirements:

Date(s) of the evaluation
The diagnosis of the disability
The documentation must be current, giving an accurate picture of how the disability impacts the student at this point in time.
For psychiatric disabilities the documentation should be current within the past year, with updates provided (as appropriate) during a student’s enrollment.

I am verifying that the named student information is correct, that the student or (family member) is a patient that I have been treating, and that I am not a relative of the student.

__________________________________________________ ___________________________

Signature of Certifying Professional Date

Cindy Dean, Director of Student Success

(859) 858-2393; FAX (859) 858-2021

Email: cindy.dean@asburyseminary.edu