AAA/ESA Consult Questionnaire | Care Beyond Campus

You're one step closer to the support you need. The questions below help us determine whether an academic accommodation assessment or ESA evaluation is clinically appropriate and how to proceed. We'll review your responses and reach out within 24 business hours to confirm your appointment.

Legal First Name

Legal Last Name

If you go by a name that's different from your legal name, please share it here so we can address you correctly.

What college/university do you attend?

Please enter the address we should use as your primary residence for care and records below.

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Which best describes this address?

On-campus housing

Off-campus housing

Permanent/family home

Other

Email

Phone

Are you currently engaged in ongoing mental health therapy?

Yes

No

If you are not, are you willing to begin therapy if recommended as part of this process?

Yes

No

What is your understanding of what accommodations are for?

Have you previously received accommodations while attending this or another institution?

Yes

No

If yes, what accommodations were previously provided?

Please select any areas of your academic functioning the challenges you're experiencing are affecting.

Completing exams or timed assessments

Sustaining attention during lectures, study sessions, or exams

Reading, writing, or processing information

Attending class consistently

Keeping up with assignments or deadlines

Participating in labs, discussions, or group work

None of the above

Other

Please select any activities of daily living/functioning the challenges you're experiencing are affecting.

Please select any specific environments or situations that significantly worsen your functioning.

If you selected "housing environment" above, please briefly describe how your current living situation affects your functioning or academic participation.

Please select any strategies or supports that you have tried to manage the challenges you're experiencing.

Over the past year, have you had thoughts of suicide or taken steps to harm yourself or end your life?

Yes

No

If you answer "yes," it does not affect your ability to receive an assessment/evaluation, it gives us the insight to plan your appointment safely.

If yes, please tell us a bit more about when that was, what was happening for you around that time, and how you're doing now.

Have you been discharged from a psychiatric hospital or inpatient program in the past 12 months?

Yes

No

If yes, please share the facility name and your approximate admission or program start date.

Are you requesting documentation for an emotional support animal?

Yes

No

If yes, how do you believe an emotional support animal will help you function academically or emotionally?

Which day(s) do you have the most flexibility to meet for your assessment/evaluation appointment?

This helps us explore which of our available appointments might work best for you.

What time(s) of day would you prefer your assessment/evaluation be scheduled for?

Morning (7a-12p)

Afternoon (12-5p)

Evening (5-9p)

Based on the availability you shared, are there any dates or times you are unavailable to meet in the next two weeks?

Please share exact dates and consider exams, study sessions, travel, competitions, events, appointments, interviews, and other non-recurring commitments.

I understand that this is a clinical evaluation and that accommodations or ESA documentation are not guaranteed.

I understand that participation in therapy may be recommended as part of this process.

Academic Accommodation Assessments (AAA) and Emotional Support Animal (ESA) Evaluations are out-of-pocket services and are not billed to insurance. Fees range from $350-950, depending on the type of evaluation and documentation needed. Specific pricing will be confirmed when we reach out to confirm your appointment.

Please confirm you understand the cost of AAA & ESA services.

If you're comfortable sharing, please let us know the specific person, office, or program that referred you.

AAA/ESA Evaluation Consultation Questionnaire

AAA/ESA Evaluation
Consultation Questionnaire