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This form must be completed by a qualified treating professional (psychologist, clinical counselor, or psychiatrist) on behalf of a student at Claremont McKenna College who is requesting an Emotional Support Animal as an accommodation. The form is confidential and is sent directly to the Assistant Dean of Students for Accessibility Services & Academic Success to be reviewed and included in the student's private accommodations record. The Assistant Dean will reach out to the Provider with any follow up questions, and with the student regarding next steps in the process. Any questions should be directed to AccessibilityServices@cmc.edu.

Provider Information

Name of treating professional

License #

Your phone number

Your email address

Your physical address

Student Information

Student name

Student DOB (YYYY-MM-DD)

Phone number

What is the nature of the student's specific disability/disorder (DSM-V)? Please include the diagnosis and its severity.

Identify the specific symptoms caused by the disability and how this substantially limits one or more major life activities for this student.

Identify any other accommodations that may be effective in allowing the use and enjoyment of campus housing. If applicable, indicate any mitigating measures that have been tried, or are currently being used, and how they alleviate or eliminate symptoms.

Does the student already have ownership of the animal?

Yes
No

Have you witnessed the patient and the proposed Emotional Support Animal interact?

Yes
No

What specific recommendations do you have for the type of animal the student should have, if they are approved for an ESA? (i.e. type, size, breed, and temperament of an animal)

As you are recommending the provision of an ESA, please describe your observations of how this specific animal mitigates your patient's symptoms.

Explain how the accommodation of an ESA is necessary for the individual to use campus housing.

Does the student understand that their animal must be able to comfortably fit into a dorm room which is small in size?

Yes
No

Have you discussed the responsibilities associated with properly caring for an animal while engaged in typical college activities and residing in campus housing?

Yes
No

Do you believe those responsibilities might exacerbate the student's symptoms in any way?

Signature of Treating Professional

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