Service Dog Preliminary Application

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

State

Zip Code

Phone Number *

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?

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?

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

Please use the scale below to indicate physical ability.

Left Hand Strength

Right Hand Strength

Left Hand Dexterity

Right Hand Dexterity

Left Arm Strength

Right Arm Strength

Left Upper-Body Strength

Right Upper-Body Strength

Left Leg Strength

Right Leg Strength

Left Leg Control

Right Leg Control

If falling is a concern for you, how often do you fall?

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?

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 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?

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?

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