Rescue 22 Foundation Service Dog Application

Thank you for your interest in receiving a service dog from the Rescue 22 Foundation [R22]. R22 provides fully task trained service dogs to veterans that 1.) demonstrate need as documented by a medical professional and 2.) would benefit from a service dog as a therapeutic tool as part of a comprehensive medical or mental health plan.

Each application is evaluated on its own merits. All information that is requested as part of this application is critical to ensure the best match possible in the selection of your service dog candidate. If you have any difficulty or have any questions for clarification while completing this application, please send an email to angela@rescue22foundation.org and we will schedule an appointment via video conference to assist you.

ALL INFORMATION GATHERED AS PART OF THIS APPLICATION IS KEPT STRICTLY CONFIDENTIAL AND WILL NEVER BE SHARED WITH A THIRD PARTY.

To qualify for an R22 Service Dog, you must meet the following criteria (other acceptance criteria may be required upon review):
i) Verifiable and documented disability diagnosis by a licensed and certified clinician or medical professional and a letter from a clinician that verifies that you are not a current inpatient client or is 6 months or more post inpatient care for substance abuse, mental health and/or suicidal ideation treatment and finally a statement that you are capable for caring for a dog and participating in handler training.

*Rescue 22 Foundation has a template letter available to send for your clinician/health care provider available and it is recommended that you utilize this template for documentation purposes.

ii) DD214 demonstrating honorable discharge, medical retirement or retirement from military service;

iii) Stable living environment and the ability to financially support a service dog;

*A self-statement of financial stability attesting that you are financially capable of caring for a dog,
including but not limited to the provision of annual veterinary care (at minimum), AAFCO-approved
dog food, required tags and licensure, breed-specific grooming, and any required medications or
medical treatments. For a detailed list see: https://www.akc.org/expert-advice/lifestyle/know-true-cost-owning-dog/

AND

*Proof of stable housing for over six consecutive months (e.g., utility bills, house lease).Group housing is not acceptable as proof of stable housing;

iv) Agreement statement from other adult(s) house members to have a dog, if appropriate;

v) Not have a conviction of any crime against animals.

Documentation Checklist

Completed ApplicationDD214Medical Professional Letter or other formal documentation of primary diagnosis (please see template)Self-attestation of financial stability and confirmation of review of expense checklist.Agreement statement from other adult house members to have a dog, if applicable.Copies of documentation for proof of stable housing.

Please upload a copy of your DD Form 214 (Member 4 Copy).

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Please upload a copy of your Medical or Mental Health Professional Documentation.

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Please upload a copy of your Financial Stability Statement.

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Please upload copies of your Financial Stability proof (lease, utilities etc)

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Please upload a letter from adults in your household that a service dog is welcome.

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Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

Primary Doctor Name and Contact Information

Psychologist or Mental Health Professional Name and Contact Information

Names and Ages of other individuals that reside in the same household.

Emergency Contact Name, Relationship, Phone number and email.

Have you ever applied for or been accepted for a service dog by another organization?

YesNoYes but the dog ended up not meeting my needs.Other

Have you ever been denied a service dog by another organization?

YesNo

If yes, please explain the circumstances for denial.

What type of support is available to assist you with the care of a service dog (veterinarian visits, feeding, bathing etc) in the event that you were unable to perform these tasks? Please be specific.

Do I really love dogs enough to have one with me at all times?

Yes, without a doubt.Yes, but I understand that it will still require an adjustment.Maybe I need to think about that a bit more.Other

Will a service dog still be a good fit for me in five, eight or ten years? Service dogs are bred to work and need a job to thrive. They require ongoing training, mental stimulation and a great deal of physical exercise to keep them strong and healthy. Are you committed to continuing this over the lifespan of your service dog?

I need to think about this.Maybe I am considering biting off more than I can chew.Yes, this will be part of my own healing process and mirrors my current lifestyle.Other

Am I okay with being visible to the public in another way? Once you have a service dog, the public takes a new interest in you in public places. Sometimes this includes asking inappropriate and invasive questions. Hidden and invisible diagnoses (like PTS or TBI) may even cause business owners or the casual observer to challenge your "need" for a service dog.

Yes, I can handle and accept this aspect of having a service dog.Yes, but I am concerned that it may trigger some anger or anxiety and I will need some coping strategies.Maybe the service dog option will make me more stressed in public and I need to reconsider.Other

Am I able to accept that utilizing a service dog is a big adjustment, especially in the first few months? Am I willing to be disciplined and consistent with the guidelines provided by the R22 trainer and reach out immediately if I require additional assistance?

Yes, without a doubt!Yes, I am apprehensive of the adjustment but I believe I will succeed.No, this is starting to sound like more trouble than it is worth.Other

Lastly, I understand that having a service dog is a huge committment. A service dog is not a pet and as such requires a great deal of additional time, effort and energy.

If at anytime you are unable or become unwilling to care for your service dog, the dog MUST BE RETURNED to the Rescue 22 Foundation. The dog may not be rehomed or put in the custody of any other person or entity.

Signature*

Date

Initials*

Select all medical conditions that apply:*

What is your primary diagnosis for which the service dog is to address?

What are the secondary diagnoses that are also applicable for which the service dog should be prepared to address?

Date of onset of primary diagnosis?*

In your own words, how would having a service dog help you with your medical or mental health diagnoses? *

What are your goals that you would like to achieve with your service dog? Please be specific.*

In your own words, describe how a service dog will assist you in becoming more independent or productive or both, at home and in your communit-please be as specific as possible.*

Please describe what an average day looks like for you (lifestyle). What does your current schedule look like at this time? How might this factor into the dog selection process? Please be as specific as possible.*

Please describe any physical traits that may be relevant to the dog selection process. What are some of your personality traits that may also factor into the dog selection process?

The Rescue 22 Foundation has a Veteran Service Officer that works directly with veterans in our program. If you have any additional service-connected issues with the VA that need attention and would like assistance, please detail here.

Alert Tasks (please select all that apply).

Closing Tasks (please select all that apply).

Forward Tasks (please select all that apply).

Leading Tasks (please select all that apply).

Provision Tasks (please select all that apply).

Turn on/turn off tasks (please select all that apply).

Carry Tasks (please select all that apply).

Drag Tasks (please select all that apply).

Help Tasks (please select all thar apply).

Mobility Tasks (please select all that apply).

Pulling Tasks (please select all that apply).

Interrupt Tasks (please select all that apply).

Open Tasks (please select all that apply).

Call tasks (please select all that apply).

Deliver Tasks (please select all that apply).

Guide Tasks (please select all that apply).

Find Tasks (please select all that apply).

.

Date

MonthDayYear

Signature

A written testament that you have not been convicted, or found not guilty by reason of insanity,in a civilian or military jurisdiction of any violent or substance abuse-related criminal offenses, andthat the SM was never convicted of any felony that resulted in incarceration longer than sixty days.

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The information that I have provided is true and represents, to the best of my ability, a true depiction of my medical and mental health needs.

Signature*

Date*

MonthDayYear

SERVICE DOG APPLICATION

Am I a good candidate for a service dog?

Medical and Mental Health Information

CUES AND TASKS

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