Name
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First Name
Last Name
Email
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Phone
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(###)
###
####
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date
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MM
DD
YYYY
Age
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Pronouns
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Place of residence
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Urban
Rural
Suburban
Type of residence
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Do you utilize mobility aids?
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Select all that apply
Where do you utalize your mobility aids? (in the home, public places, only on vacations etc)
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Please describe your medical conditions/ disabilities using general medical terminology.
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Have you received a diagnosis? (Yes or No) If "Yes" when?
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Are your conditions stable?
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Yes
No, it's progressive
Do you have any allergies? If so, please describe them.
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Can you pick items up off the ground?
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Yes
No
Can you push accessibility buttons or elevator buttons?
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Yes
No
Can you open doors?
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Yes
No
Yes, with difficulty
You live:
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Do kids live with you? If yes how manny and what ages. If no kids please list the ages of all people in your house hold and your relation to them.
Do all the people who live with you agree with your course of action?
Is there anyone in your family or social circle that does not like dogs?
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Method of transportation commonly used by applicant/ family
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Please describe your fence. What type of fence? How tall is it? Is it fully enclosed? Is your fence well-maintained and in good shape? If you do not have a fenced in yard please list your potential alternative options avaiable.
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A fenced-in yard is very good for exercising a young service dog; however, a dog also needs daily walks on leash. Is the dog’s primary handler physically able to handle the strength of a young, active 65-85 pound dog?
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Do you consider yourself knowledgeable in dog care and behavior?
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Yes
No
Are you prepared to deal with the time involved in maintaining a service dog (socializing, on-going training, exercising, grooming, toileting, etc.)?
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Yes
No
Are you able to financially commit to maintaining a service dog, which can cost over $1000 / year for veterinary care and food expenses? This does not include unforeseen circumstances.
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Yes
No
How long have you considered getting a service dog?
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Why do you feel you are ready now?
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What is your lifestyle?
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I stay at home most of the time
Active, I get out into the community often
Describe your lifestyle - list activities and outings applicant and family enjoy, including weekends, summer camps, traveling, etc.
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Where do you work?
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Have you discussed the possibility of bringing a service dog to work with your employer?
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Are you in school? (virtually or in person?)
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If you are a student in school, what grade are you in?
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Elemetary school (1-6 grade)
Middle school (7-8th grade)
High school (9-12th grade)
College (2 year)
College (4 year)
Graduate program
Not a student
Have you discussed the possibility of bringing a service dog to school with the director of your school?
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Yes
No
N/A
Please describe how you believe a service dog will be beneficial and improve your autonomy in your daily life?
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Please describe how your disability impacts your life?
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What are you currently having difficulty or unable to do that you would like to do?
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What tasks would help you accomplish what you’ve had difficulty or been unable to do due to your disability?
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How did you hear about us?
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Facebook
Instagram
Google/ Yahoo/ Internet
Referral
