Healthcare Provider/Advocate Form
Request for Disability Related Housing and Meal Plan
Accommodation(s)/Modification(s) Student Release
Student Name: _____________________________________ Date: _______________
SUID: _______________ Student Email: ______________________________
I authorize Syracuse University's Center for Disability Resources staff to receive information from the
provider or appropriate agency listed below. If further information or clarification is needed, I also
authorize my provider or advocate to discuss the relationship between my disability and the need for the
requested accommodation/modification in residential housing while attending Syracuse University.
My signature indicates that the appropriate healthcare provider, advocate, or designee has completed the
statements and documentation.
Provider Name: _____________________________________________
Contact Information: _________________________________________
Student Signature: ___________________________________________ Date: _____________
Healthcare or Agency Provider (to be completed by the provider)
To evaluate the need for a housing or meal plan accommodation or modification, Syracuse University
requires the student to be a qualified student with a disability. Under the Fair Housing Act, a disability is
defined as having a physical or mental impairment(s) that substantially limits one or more life activities.
Individuals are typically requested to submit relevant documentation from an appropriate professional,
advocate, or healthcare provider to confirm that the individual has a disability, which is what we ask that
you do, in addition to answering the questions on the next page. As such, you must be familiar with the
history and functional impact of the student's disability and the disability-related need for accommodation.
Once this information is collected, each request is reviewed on an individualized basis.
Please sign to attest that you or your designee personally completed this form, that you are familiar with
the student’s disability, and that you are not a relative of the student.
Provider Name: ______________________________________ Date: _____________
Provider Signature: ____________________________________
Contact Number: ______________________________________
Center for Disability Resources
804 University Ave., Third Floor, Syracuse, NY 13244 , [email protected] T 315.443.4498 F 315.443.1312, syracuse.edu
Date last seen by your office relative to the disability in question: _____________________
1. Describe your relationship to the student and knowledge of the student's disability.
2. Please describe the disability and/or disabling conditions, including the way that the condition(s)
impact the student’s major life activities, that you would like Syracuse University to consider in
determining whether housing accommodations are appropriate. Please also attach any relevant
information that you would like Syracuse University to consider in its review.
3. Please provide your suggestions for specific accommodations related to housing.
Questions 4 & 5 pertain to requests for an Emotional Support Animal (ESA).
4. What has been the duration of therapeutic relationship between the requester and the ESA, please
include the type of animal in question:
5. State clearly how the ESA serves a disability-related need for the requester. For example, does the
animal work, provide assistance, perform tasks or services for the benefit of a person with a
disability, or provide emotional support that alleviates one or more of the identified symptoms or
effects of a person’s existing disability?
Return Form to:
Syracuse University, Center for Disability Resources
804 University Ave. Syracuse, New York 13244-2330 Phone: (315) 443-4498
Fax: (315) 443-1312
Email: [email protected]
Center for Disability Resources
804 University Ave., Third Floor, Syracuse, NY 13244, [email protected] T 315.443.4498 F 315.443.1312, syracuse.edu
