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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
Your wishlist is empty.
View Wishlist
Login
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Service Dog Preliminary Application
Good Dogs
>
Service Dog Preliminary Application
-
Step
1
of 3
Email Address
*
Application Date
Parent / Guardian Information
*
First
Last
This information is made to be completed by parent or guardian if under 18 or unable to fulfill this information.
Parent or Guardian?
Parent
Guardian
Other
Address
*
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
Gender
Male
Female
Age
*
If the applicant doesn't live with the parent or guardian please indicate here address and or emergency contact
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 check all that apply: What are the effects of the disability?
*
Mobility impairment (such as multiple sclerosis, muscular dystrophy, paraplegia, o stroke or spinal cord)
Post-Traumatic Stress Disorder (PTSD)
Down syndrome
Attention deficit hyperactivity disorder (ADHD)
Speech Impairment
Reduced Stamina
Coordination Problems
Limited Mobility
Memory Loss
Spasticity
Slowed Development
Muscular Weakness
Cerebral palsy
Hearing Loss or deafness
Physical disability
Other
Is the applicant’s disability progressive?
Yes
No
Description of Disability(ies)
Include specific information regarding your diagnosis(es), prognosis, and limitations. List all secondary physical and/or psychological diagnosis(es).
Age at time of Diagnosis
How many hours per week are you in school or therapies?
What types of therapies are you currently involved in (including special programs at school)
You currently reside in a
House
Apartment
Duplex
Other
Other persons in your home (specify name and last name and how you are related):
Your residence currently has:
Fenced yard
Enclosed Area
Other
Do you have other pets? (list species, breed, age and sex)
Do you require the assistance of an aid or family member for daily living skills? If so, what are that person’s responsibilities and number of hours worked?
What type of service dog would meet your needs? (Please check all that apply)
Seizure Alert and Assistance
Sound Alert
Stability Assistance
Mobility Assistance
Therapy Dog (organizations or businesses)
Psychiatric assistance
List the specific tasks you need a service dog to perform to mitigate your disability(ies).
Do you (the applicant) have any problems with:
Allergies
Chronic Pain
Heightened Emotions
Depression
Balance
Brittle Bones
Heat/Cold Sensitivity
None of the above
Which device do you, the applicant, use most often? (If applicable)
Crutches
Leg Brace
Manual Wheelchair
Power Wheelchair
Hearing Aid
Crutch/Cane
Walker
Other
Next
Please use the scale below to indicate physical ability.
Please use the scale below to indicate physical ability.
Left Hand Strength
1
2
3
4
5
6
7
8
9
10
Right Hand Strength
1
2
3
4
5
6
7
8
9
10
Left Hand Dexterity
1
2
3
4
5
6
7
8
9
10
Right Hand Dexterity
1
2
3
4
5
6
7
8
9
10
Left Arm Strength
1
2
3
4
5
6
7
8
9
10
Right Arm Strength
1
2
3
4
5
6
7
8
9
10
Left Upper-Body Strength
1
2
3
4
5
6
7
8
9
10
Right Upper-Body Strength
1
2
3
4
5
6
7
8
9
10
Left Leg Strength
1
2
3
4
5
6
7
8
9
10
Right Leg Strength
1
2
3
4
5
6
7
8
9
10
Left Leg Control
1
2
3
4
5
6
7
8
9
10
Right Leg Control
1
2
3
4
5
6
7
8
9
10
If falling is a concern for you, how often do you fall?
1
2
3
4
5
6
7
8
9
10
Will you want your dog to help support you while you are walking or getting up? If so, describe.
Is mobility limited? How? Describe if you would need he dog to work on one side more than the other
Do you require the assistance of an aide or family member for daily living skills?
Yes
No
Do you have vision problems? (i.e. Corrective lenses, large font, etc...)
If yes, in which areas? be specific (i.e. Tone Variation, Easily Understood, Speech Volume, maybe you use a word board?)
Please use the scale below to indicate physical ability.
1
2
3
4
5
6
7
8
9
10
1 for Severe impairment or inability to be understood or inability to learn - 10 for No impairment or ability to be understood or ability to learn
Do you use a hearing aid?
Yes
No
What work, school, or rehabilitation program(s) have you completed?
Please describe any additional limitations: Mobility, physical strength, endurance, reaction speed, balance, vision, speech difficulties, heat, cold or pain sensitivity, your reaction to crowded locations or triggering sounds, your ability to read and understand written material, and anything else that might help us understand your needs.
Do you currently work? If so, where do you work and what type of work?
What is your current work or school schedule?
Have you owned a dog previously? If so, please describe what kind and how old you were at the time.
Have you previously owned a service or assistance dog?
Yes
No
Describe the ways you believe a Service Dog can assist you. What are your hopes, fears, goals?
A service dog needs daily training, attention and care. Are you able to provide it?
Yes
No
Maybe
Good Dogs requires bonding sessions, training clases and meeting for you to get to know your dog. Will it be difficult to meet with us before the delivery?
Yes
No
Maybe
Please explain any Yes answer about difficulties above
I understand applying for a service dog from Good Dogs Training does not guarantee I will receive a service dog from this organization.
*
I understand
Message
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