Application for a Service Dog

Application for a Service Dog
Our waitlist is currently 2-3 years. Please keep this in mind as you apply. We will hold your application on file until a Service Dog in Training matches your need. If you wish to be removed from out waitlist at any time, please let us know.

Applicants that receive a service dog must participate in team training in Tulsa, OK. This training requires several weeks.

Please note, Therapetics only trains and places Service Dogs for veterans diagnosed with PTSD and individuals living with physical disabilities that limit their mobility. Our service area is limited to the state of Oklahoma. We are able to provide referral information for other types of service dogs as well as for individuals living out of state.
The type of service dog I am interested in is:*

Mobility Assistant Service DogPTSD Service Dog (Veterans or First Responders only)Referral to a Different Organization
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Please describe your disability and tell us how a Service Dog may help you.*

Recommendations for Other Organizations
Spirit Ranch Dog Training, Tulsa, OK

https://www.tulsak-9training.com

Phone: 918-497-8855

K9 Manners and More, Broken Arrow, OK

https://k9-manners.com

Phone: 918-451-8446

Southern Warrior K9, Shawnee, OK

https://www.southernwarriork9.com

Phone: 405-400-0268

Zen Dog Oklahoma, Bristow, OK

https://www.zendogoklahoma.com/

Phone: 918-633-8464

Assistance Dogs International

https://assistancedogsinternational.org

Service Dog Application Questions
Instructions: This application is to be filled out by the applicant for the service dog. Please answer all questions as accurately and completely as possible. If the question does not apply to you, please indicate with an “N/A.” Should you have questions or need clarification, please call (918) 270‐4226.
Upload a Photo of Yourself*

Cancelof
Date of Birth*

MonthDayYear
Date
Age*
Marital Status*
Name of Significant Other
Number of Children*
Children's Age(s)
Name and relationship to any person(s) who live in your home (other than spouse/significant other and children)*
Do you have another person besides those listed above who help to care for you? If so, who?
Current Living Arrangements
Do you live...*
Type of Living Accommodations*
If you selected other, please explain below:
If a renter, please provide the name and contact information for your landlord or apartment complex.
Employment Information
Employer/School*
Employer/School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer/School Phone Number*
Please enter a valid phone number.
Job Title or Course of Study*
Year/Level (if student)
Nearest Relative
Name of Nearest Relative Not Living with You*

First NameLast Name
Relationship*
Relative's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relative's Phone Number*
Please enter a valid phone number.

Activity Profile
1. Personal Care Tasks (ex: hygiene, grooming, dressing, eating, toileting, taking medication, etc)
Things I can currently do without assistance:*
Things I cannot do or need assistance with (please also note who currently assists you):*
2. Household Tasks (ex: cooking, cleaning, maintenance, tending to pets or children, etc)
Things I currently can do without assistance:*
Things I cannot do or need assistance with (please also note who currently assists you):*
3. Work/Educational Tasks (ex: using a computer, taking notes, carrying books, answering a phone, stocking merchandise, organizing paperwork, etc)
Things I currently can do without assistance:*
Things I cannot do or need assistance with (please also note who currently assists you):*
4. Community/Social Tasks (ex: driving, shopping, visiting family, attending religious ceremonies, etc)
Things I currently can do without assistance:*
Things I cannot do or need assistance with (please also note who currently assists you):*
5. Leisure/Play Tasks (watching movies, playing sports, reading, etc)
Things I currently can do without assistance:*
Things I cannot do or need assistance with (please also note who currently assists you):*
Think about the above activities that you identified as difficult for you. Identify the top five (in order of most important to less important) that you think having a service dog would help you to be more independent.
1. Most Important*
2.*
3.*
4.
5. Less Important

Service Dog Information
What specific goals do you feel you could achieve by having a service dog?*
How do you feel a service dog will help you?*
Have you had a service dog before?*
If so, where was the dog trained?
What is the current status of this service dog?
Do you have a fenced yard or enclosed area in which a dog may exercise and relieve himself?*

YesNo
If you answered no, please describe how you will exercise the dog and take him outside to relieve himself.
What type of exercise will you provide for the dog (with or without a fenced yard)?*
Describe any pets currently in your home and how these pets interact with other animals.*
How will your family and friends respond to a service dog?*
Are there any special factors which should be considered if paired with a service dog?*
Are you planning to move outside of Oklahoma in the next 3 years? If so, please explain.*
Is there anything else you would like us to know?
If you are asked to interview with a Therapetics' staff member, will this be difficult for you? If yes, please explain.*
If you are partnered with a service dog, you will be required to participate in training classes with your dog. This training will primarily be held in Tulsa which may require travel and overnight stays. If this will cause a hardship for you, please explain below.*
The basic care (quality food and treats, medical care, grooming, etc) of a service dog requires ongoing financial support at an approximate rate of $1,200 per year. Clients are responsible for these costs when paired with a Service Dog. Will you be able to provide this support?*

YesNo
References
As part of the application process, Therapetics requires a reference from the medical professional treating you for your physical disability and/or PTSD, a reference from a veterinarian (if applicable), a health care professional reference (physical therapist, occupational therapist, or other health care professional), and a personal reference. Please provide the information requested below. If no email address is provided, Therapetics will mail a reference form for them to complete. We highly recommend that you follow up with these individual's to ensure the forms are completed in a timely manner.

Incomplete or inaccurate information will halt the application process.
Treating Medical Professional (Primary Care Physician)
Medical Professional's Name*

First NameLast Name
Medical Professional's Phone Number*
Please enter a valid phone number.
Medical Professional's Email*
example@example.com
Medical Professional's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload letter from Primary Medical Professional, if available.

Cancelof
Veterinarian
If you have pets or another service animal in your household, the information for your veterinarian is required.
Veterinarian's Name

First NameLast Name
Veterinarian's Phone Number
Please enter a valid phone number.
Veterinarian's Email
example@example.com
Veterinarian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Care Professional (physical therapist, occupational therapist, or other therapist)
Health Care Professional's Name*

First NameLast Name
Health Care Professional's Phone Number*
Please enter a valid phone number.
Health Care Professional's Email*
example@example.com
Health Care Professional's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload letter from Health Care Professional, if available.

Cancelof
Personal Reference (not living with you)
Personal Reference's Name*

First NameLast Name
Personal Reference's Phone Number*
Please enter a valid phone number.
Personal Reference's Email*
example@example.com
Personal Reference's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload letter from Personal References, if available.

Cancelof
By signing and submitting this form, I hereby grant the above listed individuals permission to release to Therapetics any information regarding my condition/disability. This information will not be used for any other purpose than to evaluate and assess my situation in consideration of making a successful service dog placement. Therapetics will keep this information confidential and will not share it with anyone but the professional staff of any agency that is involved in helping provide service for me. I also give my permission for Therapetics to contact me directly, should they need additional information.
If you understand the statement above, please type the word YES below.*
Attestation for Application to Therapetics Service Dogs of Oklahoma

I attest that the all of information in this application is truthful and accurate. I have read the Service Dog Eligibility Requirements and confirm my ability and willingness to adhere to them. I understand that the information I have provided will not be used for any other purpose than to evaluate and assess my situation in making a potential service dog placement. Therapetics will keep this information confidential and will not share it with anyone other than the professional staff of any agency that is involved in helping provide services for me/the applicant. Furthermore, I understand that a completed application is not a guarantee that a service dog will be provided to me as a client.

I have a clear understanding of the responsibilities I assume if I am paired with a service dog and promise that I will provide the appropriate care and love to the service dog every day.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

	Yes	No
An applicant must be disabled to a degree that a service dog could provide an increased level of mobility and/or self-sufficiency.Qualifying disabilities include, but are not limited to: Muscular Dystrophy, Multiple Sclerosis, Spina Bifida, Spinal Cord Injuries, Cerebral Palsy, Traumatic Brain Injury.
An applicant must have a physician’s evaluation and recommendation to receive a service dog. It is very helpful if this evaluation is completed by a Physical Medicine doctor. We have a list of doctors with this specialty who have agreed to see our applicants and can provide an evaluation for you upon request.
Service dogs are trained to assist the person they are paired with, not to provide assistance to the caregiver(s). Therefore, an applicant must have the physical ability to control and utilize a service dog without assistance from others.
Therapetics does not presently train guide dogs for the blind or visually impaired. An applicant must have the visual acuity to handle a service dog independently.
An applicant must not have a psychiatric condition that could pose a threat to the applicant, a service dog, or others.
An applicant must not pose a threat to the service dog or others
An applicant must not have had an alcohol or substance abuse problem within two years of application for a service dog.
Applicant must not have previously surrendered or had a service dog confiscated.
An applicant must be a Resident of Oklahoma, be a US Citizen and be a minimum of 13 years of age.
An applicant must have completed and passed a Criminal Background Check. If the applicant is under the age of 18 the applicant’s guardian(s) must undergo the background check.
An applicant must participate in an interview which will last approximately 1 hour.
If paired with a service dog, the applicant and/or family must be able to financially support the care of a service dog at an approximate cost of $1200.00 per year.
If paired with a service dog, the applicant will be subject to periodic home visits and will be required to recertify as a team through Therapetics on an annual basis.
If paired with a service dog, the applicant will notify Therapetics if circumstances arise in which the applicant cannot provide appropriate care and loving support for the service dog.
If paired with a service dog, the applicant must participate in approximately 100 hours of training, which will occur in Tulsa, to learn how to work with a service dog. Transportation and lodging will be at the expense of the applicant.
I understand that failure to comply with program requirements could result in the confiscation of the Therapetics Service Dog as well as any related supplies and equipment.

	Always	Often	Sometimes	Rarely	Never
Pick up items off the floor
Pick up items off a chair
Pick up items off a table
Push elevator buttons
Turn on/off wall light buttons
Open doors
Open drawers and cabinets
Push my manual wheelchair
Lift my arms
Walk/Ambulate
Carry objects across the room

	Yes	No
U.S. Veteran of any military branch or an Active duty member of any military branch of the U.S.
Diagnosed by a medical professional with Post Traumatic Stress Disorder (PTSD).
Applicant must be a US Citizen and a resident of the state of Oklahoma.
Service dogs are trained to assist the person they are paired with, not to provide assistance to the caregiver(s). Therefore, an applicant must have the ability to lead, command, control, and utilize a service dog without assistance from others.
An applicant must have the visual and hearing acuity to handle a service dog independently.
An applicant must not pose a threat to the service dog or others
An applicant must not have had an alcohol or substance abuse problem within two years of application for a service dog.
Applicant must not have previously surrendered or had a service dog confiscated.
An applicant must have completed and passed a Criminal Background Check.
An applicant must participate in an interview which will last approximately 1 hour.
If paired with a service dog, the applicant and/or family must be able to financially support the care of a service dog at an approximate minimum cost of $1200.00 per year.
If paired with a service dog, the applicant must participate in approximately 100 hours of training, part of which will occur at the Therapetics training center in Tulsa, to learn how to work with and handle a service dog. Transportation, lodging, and meals will be the responsibility of the applicant.
If paired with a service dog, the applicant will notify Therapetics if circumstances arise in which the applicant cannot provide appropriate care and loving support for the service dog.
If paired with a service dog, the applicant will be subject to periodic home visits and will be required to recertify as a team through Therapetics on an annual basis.
I understand that failure to comply with program requirements could result in the confiscation of the Therapetics Service Dog as well as any related supplies and equipment.

Application for a Service Dog

Recommendations for Other Organizations

Mobility Service Dog Eligibility Requirements

Disability Information

Disability Information

Service Dog Application Questions

Current Living Arrangements

Employment Information

Nearest Relative

Activity Profile

Service Dog Information

References