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About
Assistance Dogs can and do Change Lives!
Programs
History
Our Process
Our Team
Our Clients
In the Press
Get Involved
Puppy Raising
Volunteer
Resources
Blog
FAQ
Gallery
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Service Dog Application
Applicant's Full Name
Phone
Email
Address
Address Line 2
City
Zip Code
Applicant's Age
Applicant's Date of Birth
Parent's Name (If Applicant is a Minor)
Parent's Email
Parent's Phone
All Household Members Living with Applicant, and Their Age
Do Any Household Members Have a Dog Allergy?
Yes
No
Do Any Household Members Have a Fear of Dogs?
Yes
No
Primary Care Physician
Practice
Phone
Address
Address Line 2
City
State
Zip Code
Have You Signed a Release of Information for the Provider Lister Above?
Physical Therapist (If Applicable)
Practice
Phone
Address
Address Line 2
City
State
Zip Code
Occupational Therapist (If Applicable)
Practice
Phone
Address
Address Line 2
City
State
Zip Code
Primary Medical Diagnosis
Secondary Medical Diagnosis (If Applicable)
Primary Psychiatric Diagnosis (If Applicable)
How Does the Diagnosis Affect Daily Life?
What are the Cognitive and/or Physical Limitations
Are There Any Restrictions or Precautions We Should Be Aware of?
Is the Applicant Currently Receiving Medical Treatment?
Yes
No
If Yes, What Treatments are They Receiving?
List All Medication the Applicant is Taking and What They are For?
What, if any, Adaptive equipment is Used for Speech, Hearing or
Who Will Be the Primary Caregiver for the Dog?
Is the Applicant Physically Able to Handle the Dog Alone?
Yes
No
If no, can the Applicant of the Service Dog Assist with the Care of the Dog?
Yes
No
Are you financially able to provide food, veterinary care, and grooming for the dog?
Yes
No
Is everyone in the household aware that a working service dog is not a pet and must be treated as a working dog and not a pet?
Yes
No
Does applicant have a fenced in yard, either physical or electric?
What would be the greatest benefit to having a service dog?
Where would the service dog be required to go on a normal day?
If the applicant is a child, would a service dog be going to school?
Yes
No
Somedays
N/A
How do you feel a service dog would benefit the applicant at home?
I confirm that all of the above information is correct to the best of my knowledge
Yes
No
Name of Person Filling Out Application
Relationship to Applicant
Date
Send
