New Client Information Form

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
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? *
Additional information you'd like to share with us.

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