ANU Assistance/Emotional Support Animal Verification Form

NOTE: This form is to be filled out, in its entirety, by a professional who is currently treating the student. This professional must be unrelated to the student, and any information provided by a family member will be considered supplemental. Incomplete or insufficient information will delay the accommodation determination process. You will be emailed an electronic copy of this information upon submission.

Student Information
Student Name Student Name First Last
Provider Information
Provider Name Provider Name First Last
Title
License/Certification Number and Issuing State
Provider Email
Provider Address Provider Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Professional Visit Summary
Date of Initial Contact with Student Date of Initial Contact with Student / MM / DD YYYY
Date of Most Recent Formal Contact with Student Date of Most Recent Formal Contact with Student / MM / DD YYYY
Approximate Frequency of Contact with Student since Initial Contact
Date of Completion of Form Date of Completion of Form / MM / DD YYYY
Student Disability Information
Please describe the student's disability, listing a diagnosis (if applicable). Include the date of diagnosis and explain the evaluations/labs/tests administered used in the diagnostic process.
Please attach a copy of any psychoeducational reports, neuropsychological evaluations, or test results if available.

Attach Files
List any major life activities that are impacted by the student’s disability and indicate severity (substantial, moderate, mild). Examples of major life activities might include an impact in areas such as caring for oneself, living with a roommate, sleeping, eating, etc.
Describe how the animal works, provides assistance, performs tasks for the benefit of the student with a disability, or provides therapeutic emotional support that alleviates one or more of the student's identifiable symptoms of the existing disability.
Provide a summary of the student's present symptoms and indicate severity (mild, moderate, substantial). Specify the functional limitation of the resident's disability and how the presence of an emotional support animal mitigates these barriers.
Describe the expected duration of the student’s condition (progression, prognosis, stability, etc.).
Has the student signed a Release of Information?

Has the student signed a Release of Information? Yes No
Certification
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Full Name

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Email

ANU Assistance/Emotional Support Animal Verification Form

ANU Assistance/Emotional Support Animal Verification Form

Student Information

Provider Information

Professional Visit Summary

Student Disability Information

Certification