Pre-Application For a Service Dog (for a Veteran in San Diego)

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Pre-Application for a Service Dog (for a Veteran in San Diego)

PRE-APPLICATION FOR A SERVICE DOG
(For a Veteran in San Diego)

Important Note Before you take time to complete this Pre-Application, please note that at this time Pawsitive Teams only places fully-trained service dogs with San Diego-area Veterans to ASSIST WITH MOBILITY CHALLENGES AND/OR IF YOU HAVE BEEN DIAGNOSED WITH POST TRAUMATIC STRESS DISORDER (PTSD).

If you do not have a mobility disability AND/OR PTSD, please do not complete this Pre-Application.

Pawsitive Teams places service dogs with persons living only in San Diego.

This Pre-Application for San Diego Veterans Service Dog Placement is not a formal application. It is an inquiry so we can learn a little about you as a potential applicant. We will not require the formal application until we determine if you are both an excellent candidate and we have an appropriate dog. All inquiries are kept in our files for future matching. Potential applicants are screened to determine individual needs and the ability to benefit from a service dog and to provide a safe and healthy environment for the dog.

THE PLACEMENT MATCHING PROCESS
We wish we could provide a dog to each person who contacts us, but we're careful not to make promises we can't keep—the match between dog and disabled handler is an important part of the formula for a successful team. We do not place dogs based on the date a person first contacts us. Because we are a small program and cannot guarantee a match for every applicant, we encourage you to also check with Assistance Dogs International (ADI) as they have links to their member organizations and many of those place dogs with veterans. Once you submit this Pre-Application for San Diego Veterans Service Dog Placement form, we will reply to you with a personal email.

SAN DIEGO VETERANS SERVICE DOG PLACEMENT PRE-APPLICATION CONFIDENTIALITY
Please be assured that all information related to your condition and needs provided shall be held confidential by Pawsitive Teams. None of the information will be released to any agency or person outside of the Pawsitive Teams training team without your express written consent.

In order to submit this pre-application for a service dog, you must be a San Diego resident and have no plans to relocate for at least one year—if BOTH of those statements are true, please continue.

QUESTIONS? Contact us at [email protected].

PRE-QUALIFYING INFORMATION

Do you live in San Diego County?

Yes

Do you plan to remain in San Diego for at least 12 months?

Yes

COMPLETING THIS FORM

Who is completing this form?

ApplicantOther

Name of person completing form (if different from Applicant).

Relationship to Applicant

PERSONAL INFORMATION

Applicant First Name

Applicant Last Name

Street Address

City

State

Zip Code +4

Please enter Zip Code +4. Example: 81432-1234

Preferred Email

Preferred Email Type

Preferred Phone Number

Preferred Phone Type

Applicant's Date of Birth

Enter date of birth. MM/DD/YYYY

Gender

Height

Weight

Please enter your weight in pounds Example: 185

Dates of Service

Date of Discharge

Rank at Discharge

BACKGROUND INFORMATION

Primary Disability

Secondary Disabilities (answer None if applicable)

Date of initial diagnosis?

Active duty injury?

YesNo

Provide additional details regarding your current medical and psychological diagnoses that may be helpful.

Specify your physical and emotional limitations.

Are you able to provide a copy of your DD214 at a later date?

YesNo

Have you been reviewed by a medical board within the last twelve months?

YesNo

Do you require special equipment or assistive technology?

YesNo

List any special equipment or assistive technology you use: (i.e.. cane, wheelchair, van with lift, walker, braces, speech board, other devices)

Have you experienced a stroke, head, or brain injury?

YesNo

Please add details about any stroke, head, or brain injury and how they've affected your daily life.

Are there any life-threatening aspects to your disability?

YesNo

Please provide information about the life-threatening aspects of your disability.

When was the last time you were hospitalized and for what reason?

Do you have a person or people in your life who could take care of your dog for an extended period of time if you had to go into the hospital or became ill?

YesNo

If no, please describe your situation regarding the absence of dog care help.

PHYSICIAN INFORMATION

Would you grant your physician(s) permission to provide us with relevant health information?

YesNo

RESIDENCY AND LIFESTYLE INFORMATION

Select your home type

Select your yard type

Are you expecting a major life change in the next year? (i.e. marriage, a baby, return to school, divorce, employment change, living alone, etc.)

YesNo

Please provide details about your upcoming major life change(s).

Do you have other people living in your home?

YesNo

Please provide names, ages, and relationship of each person living in the home or providing care on a daily basis.

How do you get around town? (i.e. personal vehicle, public transportation, friends).

Do you have a valid US driver's license?

YesNo

In which state?

Have you ever been convicted of a felony?

YesNo

ANIMALS IN YOUR LIFE

Describe your prior and current experience with dogs.

Do you currently have other animals living in your home?

YesNo

List all animals living in your home."

Do you or any household member have a dog or other pet(s) that a service dog would need to get along with?

YesNo

Explain which household member(s) have a dog or other pets that a service dog would need to get along with.

Is anyone in your household allergic to animals?

YesNo

Please list the members in your household who are allergic to what animals.

Are all household members supportive of a your desire to have a service dog?

YesNo

Explain why not everyone in your home is supportive of having a service dog.

Are you physically capable of handling, exercising, and caring for a 65-85 pound dog? Most service dogs are retrievers that need adequate exercise in order to maintain a balance in energy level necessary for service dog work.

YesNo

Explain the reason(s) you're not physically capable of handling, exercising, and/or caring for a 65-85 pound dog.

MISCELLANEOUS INFORMATION

What prompted you to apply now for a service dog?

Have you ever had a service dog?

YesNo

Please tell us about your previous, personal service dog experience.

Do you feel you're capable of achieving and maintaining the leadership role in a relationship with a service dog?

YesNo

Describe concerns you have about being a leader.

What specific tasks could a service dog perform for you?

How did you hear about Pawsitive Teams?

Why did you specifically apply to Pawsitive Teams?

Would you be able to meet the financial commitment required to maintain your dog's ongoing needs after placement? (i.e. food, grooming, health care).

YesNo

Elaborate about your financial situation.

We recognize this is an important time for you. Within the next couple of years, do you anticipate either attending school, volunteering in the community, and/or seeking employment for your current skills?

YesNo

Please give details about any new school, volunteering, and/or work experience you anticipate in the next couple of years.

Please be assured that all information on this form shall be held confidential by Pawsitive Teams. None of the information will be released to any agency or person outside Pawsitive Teams without your express written consent.

After completing this entire form, click on the SUBMIT button below and we will contact you with a personal reply in a timely manner. If you don't hear from us within 14 days, contact us at [email protected] or by phone at 858-558-7297.

Also, If you do not receive an email within 24 hours confirming your pre-application has been successfully submitted, contact us at [email protected] or by phone at 858-558-7297.

I certify that all statements I have made in this form are true to the best of my knowledge.

YesNo

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Pre-Application for a Service Dog (for a Veteran in San Diego)

PRE-APPLICATION FOR A SERVICE DOG(For a Veteran in San Diego)

PRE-APPLICATION FOR A SERVICE DOG
(For a Veteran in San Diego)