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

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

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

Pawsitive Teams places service dogs with persons who have a mobility-limiting disability, who live in San Diego County, and who have no plans to leave San Diego County for at least one year.

We do not train or place dogs for seizure response, hearing alert, psychiatric disabilities, autism, or developmental disabilities.

ABOUT THIS PRE-APPLICATION

This "Pre-Application for Service Dog Placement" is not a formal application. It is an inquiry so we can learn more about you as a potential applicant. We do not require a formal application unless we feel 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)—many ADI member organizations place dogs with veterans.

QUESTIONS? Contact us at [email protected].

Once you submit this Pre-Application for Service Dog Placement, we'll reply to you with a personal email.

PRE-QUALIFYING QUESTIONS

You must be able to answer YES to all three of the following questions to continue:

Do you have a mobility-limiting disability?

YES

Do you live in San Diego County?

YES

Do you plan to remain in San Diego for at least one year?

YES

THE BASICS

Applicant First Name

Applicant Last Name

Who is completing this form?

ApplicantOther

Name of person completing form (if different from Applicant)

Relationship to Applicant

If Applicant is a minor, please list name of Parent or Guardian.

Applicant Street Address

City

State

Zip Code +4

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

Preferred Email

Preferred Email Type

Phone Number

Preferred Phone Type

Applicant's Date of Birth

Enter date of birth as MM/DD/YYYY

Gender

Height

Weight

Weight in pounds. EX: 180

YOUR CURRENT LIFESTYLE

Are you employed and/or in school?

YesNo

Please provide employment and/or school details:

Please tell us a bit more about yourself. Include what a typical day might look like. Describe your home life, social activities, hobbies, travel, any volunteering, and your lifestyle in general.

Are you expecting a major change in your current way of life in the next year?

YesNo

Describe any major change you expect in your current way of life within the next year (i.e. marriage, a baby, return to school, divorce, employment change, living alone, other):

ABOUT YOU AND A SERVICE DOG

What specific tasks could a service dog perform for you? Be as detailed as possible.

What prompted you to apply for a service dog now?

Why did you apply to Pawsitive Teams in particular?

Have you applied to another service dog program?

YesNo

If so, which program(s) and how long ago?

Has a service dog been placed with you in the past?

YesNo

If a service dog has been placed with you in the past, please provide more information:

In general terms, describe your experience with dogs.

Are you physically capable of handling, exercising, and caring for a 65-85 pound dog?

YesNo

If you are not physically capable of handling, exercising, and/or caring for a 65-85 pound dog, please explain your situation. Most service dogs are retrievers that need adequate exercise in order to maintain a balance in energy level necessary for service dog work.

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

YesNo

Describe concerns you have about being able to achieve and maintain the leadership role in a relationship with a service dog:

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 on your financial situation that would affect your ability to meet the financial commitment required to maintain a service dog:

YOUR MEDICAL BACKGROUND & CURRENT SITUATION

What is the primary medical condition, illness, or injury that disables you?

What was the date of onset or diagnosis?

Would you grant your physician(s) permission to provide Pawsitive Teams with relevant health information and to speak with us on your behalf?

YesNo

List any frequently recurring conditions requiring medical management.

Do you have secondary disabilities or other health problems?

YesNo

Please describe secondary disabilities or other health problems:

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

YesNo

Provide details about your stroke, head, or brain injury:

Do you have any cognitive impairments?

YesNo

Detail your cognitive impairment(s):

Do you have learning difficulties that you are aware of?

YesNo

Provide more information about any learning difficulties you may have:

Are there any life-threatening aspects of your disability?

YesNo

Describe the life-threatening aspects of your disability:

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

EQUIPMENT & TRANSPORTATION

Do you use special equipment or assistive technology?

YesNo

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

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

Because our transition training includes occasional outings to a variety of locations throughout San Diego County, please describe transportation methods available to you.

YOUR IMMEDIATE HOUSEHOLD & SUPPORT SYSTEM

Select your home type

Select your yard type

Please provide the name, age, and relationship of each person living in your home or providing care for you on a daily basis.

Is everyone in your home supportive of your desire to obtain a service dog?

YesNo

If someone in your home is not supportive of you having a service dog, explain what the issues are:

Do you currently have other animals living in your home?

YesNo

List all animals living with you.

Are you or other members living in your household allergic to animals?

YesNo

Explain who in your household is allergic to what type(s) of animals.

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.

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

YesNo

Please describe your situation regarding available care for a dog:

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

YesNo

Please rest assured that all information you provide related to your condition and needs will be held confidential by Pawsitive Teams. We will not discuss or release any of your information to any agency or person outside of the Pawsitive Teams training team 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.

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

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

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