Application Agreement
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Service Dog
Application Form
If you have any questions about the application, or the application process, please feel free to email us at apawsitiveapproachtraining@gmail.com
This form can be completed over time. If you do not have the time to complete this form in one setting, please provide your email below so you can save your progress.
I certify that I am one of the following:
- I am the hopeful recipient applying for the service dog and am over the age of 18
- If the intended recipient of the service dog is a minor, I am the parent or legal guardian completing this form on their behalf
- I am a person, over 18 years of age, assisting the intended recipient of the service dog due to a limitation created by their disability or medical condition.
Yes, I Certify
Thank you for considering
A Pawsitive Approach Dog Trainin
g for your service dog. Our training guidelines are set to maximize success between a service dog and his or her handler and family.
To further ensure success for both parties,
A Pawsitive Approach Dog Training's
program requires a focused dedication from you, your family, the service dog, and the trainer. This dedicated commitment, at minimum, is around 20 hours per week when actively training and can go as high as 30 hours when necessary. Most of the training is scheduled Monday-Friday with group attendance scheduled on the weekends.
All information provided will be used strictly for internal
A Pawsitive Approach Dog Training
purposes. We do not share any client information or forms with outside parites.
Any false information provided to
A Pawsitive Approach Dog Training
by the applicant will no longer be considered for a service dog and/or service dog training and will be dismissed from consideration by
A Pawsitive Approach Dog Training
.
This application does not guarantee a placement of a service dog. This application is to determine whether or not the applicant is suitable for our program with
A Pawsitive Approach Dog Training
.
I understand and acknowledge that
A Pawsitive Approach Dog Training
must assess all dogs and puppies planning to be trained to become a service dog. This includes any potential puppies or prospective dogs. Please note all assessments have an assessment fee plus travel times.
I Understand and Agree
If you have any questions about the application, or the application process, please feel free to email us at
apawsitiveapproachtraining@gmail.com
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Contact Information
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Service Dog
Application Form
Applicant Name
I am completing this application for:
Please indicate if for yourself or for someone else.
Myself
My Child
My Spouse
Other
Myself
If for someone else, please explain:
Date of Birth
Mailing Address
Email
Preferred method of contact
Phone
How did the applicant or legal guardian hear about A Pawsitive Approach Dog Training?
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Disability / Medical Condition
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Service Dog
Application Form
What is the disability or medical condition?
Autism Spectrum Disorder
Diabetes
Post Traumatic Stress Disorder
Epilepsy
Psychiatric Disorder
Other:
Nature of the applicant's disability and length of diagnosis:
Do you have difficulty with anger management?
Yes
No
Does the applicant use a mobility assisting device such as a wheelchair?
Yes
No
Is the applicant diabetic?
Yes
No
Which type?
Type 1
Type 2
Not Applicable
Other:
Does the applicant experience seizure episodes?
Yes
No
What type of seizures does the applicant have?
(Grand Mal, Petit Mal, Partial-Complex, Cluster, Absence, etc.)
What is the frequency of seizure activity?
(Daily, weekly, monthly, etc.)
Is the applicant on the Autism Spectrum?
Yes
No
Select any of the activities the applicant has experienced in the last year:
Meltdowns at home
Fixating on specific activities
Meltdowns at school
Bolting
Meltdowns in public
Not Sleeping Well
Kicking, hitting, pinching, or biting
Self-stimulation (stimming)
Wandering / Getting Lost
Anxiety or fears of places or objects
Fixating on specific objects
Please describe the effects of Autism on the applicant and their family:
Consider including things such as work difficulties, relationships, and any physical difficulties that have come about due to the diagnosis and the caring of the applicant..
Is the applicant a Veteran?
Yes
No
Branch of Service?
Is the applicant's disability service connected? Did they become disabled while enlisted in the military?
Yes
No
Is the applicant's disability combat related? Was the applicant in combat zone when disability occurred?
Yes
No
Please describe the effects of the disability on the applicant and their family:
Consider including things such as work difficulties, relationships, and any physical difficulties that have come about due to the diagnosis and the caring of the applicant..
Has the applicant discussed this application with their doctor?
Yes
No
Is she/he in favor of the applicant getting a service dog?
Yes
No
Other:
Please list all medications the applicant takes:
Please list ALL physicians who currently treat the applicant and list their field of specialization.
Name
Specialization
Add more
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Daily Life/ Home Situation
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Service Dog
Application Form
Describe an average day – tell us about the applicant's routine, schedule, activities, etc.
Please check all that apply to the applicant's physical residence and describe in depth below:
House
Handicapped Accessible
Apartment
People Walking With or Without Animals
Two Stories
Urban Busy Neighborhood
More than Two Stories (basement, third floor, etc...)
Rural Area
Does the applicant have many visitors?
Yes
No
Does the applicant Rent or Own their residence?
Rent
Own
Other:
Has the applicant discussed having a dog living on premises with their landlord?
Yes
No
Please list the attendant care the applicant receives, including the services provided to the applicant and their schedule:
Does the applicant live with others?
Yes
No
Are there any other disabilities in your household?
Yes
No
Please list who else lives in the same home as the applicant:
Name
Relationship
Age
Comments
Add Another Person
What activities does the applicant perform on their own? Please describe:
Situation (Errands, Work, etc)
How Often?
How Long?
Comments
Add Another Situation
Does the applicant have any pets? Please list their species and living situation.
Yes
No
(example: cat, 7 years, inside)
Does the applicant have a fenced in yard? Please describe the height and material used for the fencing, and size of yard.
Yes
No
(example: 5120 sq. ft. yard, 10 ft. tall wooden fence, 10 years old, etc...)
Does the applicant have any family members or carers with dog allergies or are fearful of dogs?
Yes
No
Please Explain in Detail:
Has the applicant ever had a dog?
Yes
No
Did the applicant train their dog?
Yes
No
Please Explain:
What type of relationship did the applicant have with their dog?
Does the applicant have plans to move or relocate within 2 years?
Yes
No
Please Explain:
Are you willing to participate in an on-going weekly training session once you get a service dog?
Yes
No
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School / Work
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Service Dog
Application Form
What Is the highest level of school completed by the applicant?
No Formal Schooling
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade No Diploma
High School Graduate
GED or equivalent
Some College, No Degree
Associate's degree: occupational, technical or vocational program
Associate's degree: academic program
Bachelor's Degree
Master's Degree
Professional Doctorate Degree
Academic Doctorate Degree
No Formal Schooling
Does the applicant attend school?
Dogs are not always permitted to accompany their partner to school
Yes
No
Other:
(City, State)
Length of time at current school?
Does the applicant use a shadow or aide?
Yes
No
Other:
Are there any other animals in the applicant's classrooms?
Yes
No
Are there any other animals in the building where the applicant goes to school?
Yes
No
Please list them here.
Has the applicant discussed this application with their principal or superintendent?
Yes
No
Does the applicant have their support?
Yes
No
Other:
Is the applicant employed? If so, where?
Yes
No
Other:
(City, State)
Length of time at current employer?
Are there any other animals in the applicant's workspace/office?
Yes
No
Are there any other animals in the building where the applicant works?
Yes
No
Has the applicant discussed this application with their employer?
Yes
No
Does the applicant have their support?
Yes
No
Other:
Please list them here.
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Transportation
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Service Dog
Application Form
Vehicle Type
None
Micro Car (ex: Chevy Spark, Ford Fiesta)
Sports Car (ex: Chevrolet Corvette, Ford Mustang)
Sedan (ex: Chevy Cruze, Ford Taurus)
Hatchback Sedan (ex: Chevy Cruze, Ford Focus)
Compact Utility (ex: Chevy Trax, Ford Escape)
SUV (ex: Chevy Tahoe, Ford Explorer)
Pickup Truck (ex: Chevy Silverado, Ford F-150)
Mini Van (ex: Dodge Grand Caravan, Chrysler Pacifica)
Van (ex: RAM ProMaster, Ford Transit 250)
None
Add Another Vehicle
Does the applicant drive?
Yes
No
Does the applicant take a taxi or ride a bus or rail?
"Taxi" includes any ride sharing services, such as Uber or Lyft.
Yes
No
How Often?
Everytime
Sometimes
Most of the time
Rarely
Does someone else drive the applicant?
This DOES NOT include taxi, bus, or rail services.
Yes
No
How Often?
Everytime
Sometimes
Most of the time
Rarely
How often does the applicant transport to different locations or events? Please include any regular occurring activities.
examples: work, shopping trips, family activities, groups/clubs, religious meeting, errands, or doctors appointments.
Activity
How Often?
Where?
Comments
Add Another Activity
Does someone accompany the applicant in public?
Yes
No
How Often?
Everytime
Sometimes
Most of the time
Rarely
Please describe:
example: Jane Doe - helps with shopping, Once a week, Helps with loading and unloading groceries.
Person or Role
How Long?
Support Provided
Add Another Activity
Does the applicant travel long distances?
Yes
No
Please describe:
How often do you fly on a commercial airline?
Less than 1 time a year
Usually 1 time a year
Usually 2 - 5 times a year
Usually 6 - 12 times a year
More than once a month
Less than 1 time a year
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Applicant
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Service Dog
Application Form
When the applicant is having a tough time, what things do they do to distract, calm down, or make them feel better?
What do you like to do for fun?
During the last 12 months, how often did you usually have any kind of drink containing alcohol?
By a drink we mean half an ounce of absolute alcohol (e.g. a 12 ounce can or glass of beer or cooler, a 5 ounce glass of wine, or a drink containing 1 shot of liquor)
Every day
5 to 6 times a week
3 to 4 times a week
Twice a week
Once a week
2 to 3 times a month
Once a month
3 to 11 times in the past year
1 or 2 times in the past year
Every day
Do you think you may have a problem with alcohol, or other mood altering substances?
Yes
No
Are you involved in therapy to address any of the above issues? If so, would you provide us with a release to talk to your therapist?
Yes
No
Please list at least three references (non-family members).
Name
Relationship to Applicant
Address
Phone
Add Another Reference
May we contact these references?
Yes
No
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Service Dog I
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Service Dog
Application Form
How would getting a service dog change the applicant's outlook on the future? Please include as much as you can about the affects a service dog would have on the applicant and their family.
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Service Dog II
82
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Service Dog
Application Form
What size and breed of dog does the applicant prefer?
Select all that apply.
Toy (up to 12 pounds)
Small (12 to 25 pounds)
Medium (25 to 50 pounds)
Medium Tall (25 to 50 pounds but look larger due to lean frame or long legs)
Large (50 to 100 pounds)
Extra Large (over 100 pounds)
Other:
what breed(s) do you prefer?
Choose eight of the following words that describe traits the applicant would like to have in a dog.
Assertive
Excitable
Serious
Attentive
Happy
Slow
Calm
Independent
Smart
Communicative
Protective
Stable
Confident
Playful
Stubborn
Dependable
Resistant
Submissive
Easy Going
Responsible
Trusting
Energetic
Sensible
Willing
Choose eight of the following words that describe traits the applicant would
NOT
like to have in a dog.
Assertive
Excitable
Serious
Attentive
Happy
Slow
Calm
Independent
Smart
Communicative
Protective
Stable
Confident
Playful
Stubborn
Dependable
Resistant
Submissive
Easy Going
Responsible
Trusting
Energetic
Sensible
Willing
What tasks or skills would the applicant like the service dog to exhibit?
Select all that apply. Please note there are more tasks than what are listed here. If accepted for a Service Dog, the trainer will assist the client in better determining what tasks their Service Dog should learn.
Alert to changes in patterns (breathing, heart rate, etc)
Alert to emotional episode
Alert to hyper-focus
Alert to increase or drop in heart rate
Alert to oncoming hypoglycemic or hyperglycemic episode
Alert to presence of others
Assist handler in crossing streets safely
Brace or counterbalance handler*
Close door to block noise (noise sensitivity, etc)
Deep Pressure Therapy
Find keys, telephone, or other objects (memory issues, etc)
Find or retrieve medication (memory issues, episode, etc)
Focus/interact until sleep preparation initiated (insomnia, etc)
Give identification documents to others for assistance
Ground handler
Guide handler to a safe place (when handler is overwhelmed or disoriented)
Hallucination Discernment (alert to reality)
Help remove socks or other clothing
Initiate desired/needed interpersonal interaction (social withdrawal, etc)
Interrupt repetitive behavior (stimming, rocking, etc)
Keep handler in bed (sleep disruption, etc)
Lead handler to specific location on cue (home, seat, etc)
Lead handler to specific person on cue (friend, family member, etc)
Non-aggressively search house for intruders*
Non-aggressively stand between handler and others
Prevent self-mutilation or self-harm (head banging, skin picking, etc)
Provide signals regarding emotions (overwhelm, etc)
Remind handler of daily routines (medication, etc)
Remind handler to go to bed (Insomnia, etc)
Tactile Stimulation "Breaking the Spell"
Turn off lights (light sensitivity, etc)
Turn on light (night terrors, fear, hypersomnia, etc)
Wake up handler (Night terrors, Hypersomnia, etc)
Warmth Stimulation
Other:
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Service Dog III
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Service Dog
Application Form
If selected as a candidate for a Service Dog, will the applicant (or legal guardian) be financially able to cover cost of Service Dog Training? It ranges from fifteen ($15K) to twenty-five ($25K) thousand dollars over a period of up to four years, paid monthly without interest.
Yes
No
How much does the applicant (or legal guardian) believe they will spend annually on supplies, care, vetting, food and other required expenses for their Service Dog?
Quality dog food, supplies, vet care and Heartworm & Flea preventative is expensive and can cost around $1,500 per year. Is the applicant (or legal guardian) able to be responsible for that expense?
Yes
No
Service Dogs trained by A Pawsitive Approach Dog Training are required to be under the care of a veterinarian and on Heartworm and Flea preventative. A Pawsitive Approach Dog Training will perform undisclosed unscheduled veterinarian wellness checks on any dog in the program. For more information about Heartworms, watch the video below.
Does the applicant know of a Veterinarian to use for the care of their Service Dog?
Yes
No
How will the applicant transport their dog to the Veterinarian?
(ex: back seat in a kennel)
How and where will the Service Dog be properly exercised?
Where will the Service Dog toilet?
Who will clean up when after the Service Dog as needed?
How will the Service Dog be fed and given water at home?
(ex: fed morning and evening, before exercising, water bowls will be located around the home and cleaned and filled daily or as needed.)
How will the Service Dog be fed and given water during outings or travel?
Does the applicant's schedule permit them to spend 30-60 minutes daily training and grooming their Service Dog?
Yes
No
Who will provide support to care for, train, and exercise the applicant's Service Dog on a regular basis?
How does the applicant's family and friends feel about them getting a Service Dog?
List three people or more who could care for the applicant's service dog if they were hospitalized.
Name
Address
Phone
Email
Add Another Person
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Signature and Payment
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Service Dog
Application Form
I certify that all information provided by the applicant is truthful and completed to the best of their ability.
Clear
I certify that all information provided by the applicant is truthful and completed to the best of their ability.
Please type your name below
Please state your address and preferred contact method below
Submit this Application
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