New Client Information Form
Thank you for taking the time to inquire about our Service Dog Training Program. Please complete the information below and a representative will contact you so we can assist you.
What's your first and last name?
*
First Name
Middle Name
Last Name
Suffix
Phone Number
*
-
Area Code
Phone Number
E-mail :
*
Where the confirmation will be send to
What type of services do you require?
*
Basic obedience for my pet
I have a dog and would like it to be trained as a service dog to assist me in my daily life
I require a service dog but do not have a dog yet
Services Dogs are trained to perform specific tasks to assist a person with a disability. What area do you see a service dog assisting you?
*
Medical Alert (seizure disorder)
PTSD
Autism Support
Mobility Assistance
Anxiety Disorder
Depression
Other
Do you have any pets in the house currently?
*
Yes
No
If so, how many and what types?
Do you understand the level of care a service dog needs?
*
Yes
No
Do you possess the ability to provide financially, physically, and emotionally for a dog?
*
Yes
No
On a scale of 1-5, how ready are you to commit to a service dog and the training required?
*
1
2
3
4
5
Additional information you'd like to share with us.
0/500
Submit
Should be Empty: