To be completed by the provider:

What are the students medical or mental health diagnosis?

Date diagnosed:

Describe in detail to what extent and with what frequency the student is impacted by disability symptoms:

Does the student require on-going treatment?

Describe in detail how the student's mental health impairment has affected their functioning (that is, how is the student substantially limited)? Note: Federal law defines a person with a disability as someone who has a physical or mental impairment that substantially limits one or more major life activities. That suggests that a diagnosis (label) does not necessarily equate with a disability (substantial limitation).

When was your last interaction with the student about this mental health diagnosis, and how frequently do you meet?

What therapeutic procedures are being used for treatment purposes?

What specific symptoms will be reduced by having an ESA, and how will those symptoms be mitigated by the presence of the ESA? General evaluations are not enough. “The animal alleviates anxiety,” for example, is overly generic and fails to clarify how the animal can lessen the symptoms of this student's impairment.