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About Us
Online Courses
Separation and Isolation anxiety
Crate Training
Fetch
Close
Private Classes
Service Dogs
Application Process
Our Service Dogs
Paws Up Blog
Contact
Cart
Cart
0
Your cart is empty.
Wishlist
0
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View Wishlist
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Autism Assistance Preliminary Application
Good Dogs
>
Autism Assistance Preliminary Application
-
Step
1
of 2
Email Address
*
Application Date
Parent / Guardian Information (This information should be completed by the applicant’s parent(s) or guardian(s) if the applicant is under 18. The applicant is the individual who will be directly supported by a service animal)
*
First
Last
Parent or Guardian?
Parent
Guardian
Country of Citizenship
*
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Next
Aspirant Information
*
First
Last
Age
Gender
Male
Female
Primary Diagnosis
Age at time of diagnosis
With whom does the applicant live?
Is the applicant currently in school?
Yes
No
If so, do they want their dog to assist them while in school and if so, in what way? ** *Our dogs do not go to school unless approved by the school/teacher and aftercare coordinator if applicable.**
Please describe the most significant symptoms of the illness and how it affects the applicant
List medications, dosage and frequency:
Does the applicant have seizures?
Yes
No
What type of seizures does the applicant have?
How often does the applicant have seizures?
If the applicant has seizures, what treatments or medications are you using or have you used to control your seizures?
Does the applicant use any of the following? (Check all that apply)
Prosthesis
Leg Brace
Manual Wheelchair
Power Wheelchair
Wrist Brace
Hearing Aid
Crutch/Cane
Walker
Other
None of above
Please indicate any of the following conditions that may apply:
Panic Attacks
Violence: To self, To others, To property
Mood Swings
Hallucinations
Nightmares
Night Awakenings
Racing thoughts
Medication side effects
Distractibility
Suicidal Behaviors
Self Stimulating Behaviors Disassociation
Impulsivity
Poor judgment
Self care deficits
Difficulty managing
Difficulty completing tasks
Applicant Bolts or runs away
Other
Please describe any additional conditions or scenarios you would like to explain in the box below. Also, please add a description of any condition you indicated above in the space below:
How do you see a service dog helping your applicant?
Do you have other pets? (list species, breed, age and sex)
Is anyone in your home allergic to dogs or pet dander?
Yes
No
Have you previously owned a service or assistance dog?
Yes
No
Have you ever owned a dog in the past?
Yes
No
Does the dog live primarily Inside or outside?
Inside
Outside
Who was responsible for the dog’s training and care?
In order to keep the service dog’s training sharp, the trainers will need to train adults in the family in order to maintain the training. Who will be responsible for keeping up the training each week?
Additional information
A service dog needs daily training, attention and care. Do you have time to spend with the dog?
Yes
No
Phone
Submit
