PTSD Application

PTSD service dogs are taught behaviors that help people with PTSD to better cope with fear and anxiety. These dogs can provide a physical barrier between their partner and the public while providing a social bridge, provide stress reducing pressure on trained body points and provide behaviors to alleviate flight or fight responses. These dogs have full public access rights under the Americans with Disabilities Act (ADA).

This Application must be completed by the applicant. Medical Prescription for a Service Dog & Copy of Military ID Card or DD Form MUST accompany application. You may upload them at the end of the application or send them in a separate email.

APPLICATION FOR SERVICE DOG

Personal Information

Date:*

MonthDayYear

Full Name of Applicant:*

First NameLast Name

Address:*

Street Address

Street Address Line 2

CityState

Zip Code

Home Phone:*

Please enter a valid phone number.

Work Phone:*

Please enter a valid phone number.

Mobile Phone:*

Please enter a valid phone number.

Email:*

example@example.com

Emergency Contact Name:*

First NameLast Name

Emergency Contact Number:*

Please enter a valid phone number.

Height:*

Ex: 5 ft 8 in

Weight:*

Ex: 170 lbs

What is the Applicant's Full Diagnosis?*

Date of Birth:*

MonthDayYear

Gender:*

Marital Status:*

Where Are You Employed / Attend School?*

City:*

State:*

Length of Present Employer / Yrs at School?*

Ex: 5 years

If In School, Do You Use a Shadow or Aide?*

Applicant's History

Describe the applicant's:

Activity Level*

Does the Applicant Use a Wheelchair?*

If Yes, Is It Electric or Manual?*

Is One Side of the Applicant's Body Stronger Than the Other?*

If Yes, Which Side?*

With One or Both Hands, Is Mobility Limited?*

Please Explain How Mobility Is Limited*

Is the Applicant Restricted in the Use of Their Hands or Arms?*

If Yes, How So?*

On a scale of 1 to 5 (1=poor, to 5=excellent) describe applicants:

Upper Body Strength:*

Range of Motion:*

Grip Strength:*

Living Arrangements

Where Do You Live?*

Current Housing:*

Name / Location of the Home:*

Ex: Oakwood Apartments, Mission Hills, CA

Yard:*

Do You Rent or Own?*

If Renting, Have You Discussed Having a Dog Living On Premises With Your Landlord?*

List All People Residing With You In Your Home:

Name: Full Name    Relationship: Mom, Dad, Sister, etc. Age:  Ex: 25 years old

Name: Full Name    Relationship:  Mom, Dad, Sister, etc.  Age: Ex: 25 years old

Name: Full Name    Relationship:  Mom, Dad, Sister, etc.  Age: Ex: 25 years old

List Three People Who Could Care For Your Service Dog If You Were Hospitalized

Name:  Full Name* Address:   Street Address*      City*   State*   Zip*
Phone: Phone Number* Email:   Email*

Name:  Full Name* Address:  Street Address*      City*   State*   Zip*
Phone:  Phone Number* Email:   Email*

Name:  Full Name*   Address:   Street Address*      City*   State*   Zip*
Phone:  Phone Number*  Email:   Email*

Your Training with the Dog

Are You Able To Take Time Off Work/School to Attend a One-Week Training Session At One of Our Training Locations to Learn How to Work Your PFLK9R dog? *

Have You Ever Attended Dog Obedience Classes? *

What Level?*

Are You Willing to Participate in an On-Going Training Session Once You Get a Service Dog? *

Dog Information

A successful assistance dog applicant must be able to care for the daily need of his or her dog. Therefore, we ask you to consider and answer the following: (please indicate if you are unable to do a certain task.)

Where Will Your Dog Be Taken For Toilet Requirements? *

When Do You Get Out of Bed In the Morning?*

What Time Do You Retire In the Evening?*

Will the Dog Be Exercised and Have Play Time?*

Have You Ever Had a Pet Dog Before?*

Do You or Anyone In Your Household Have a Dog Now?*

If So, What Is the Age?*

Numeric Value Only

Sex:*

Neutered / Spayed:*

How Many Hours Per Day Would the Dog Be Left Alone?*

Numeric Value Only

Is There A Particular Type / Breed Dog That You Do Not Like?*

The Size of Dog You'd Prefer?*

All dogs are taught basic dog obedience and socialized in public situations. Describe the ways you believe a service dog can assist the applicant in activities or daily living?*

	YES	NO	FREQUENCY (Ex: Sometimes, All the Time)
Indoor/Outdoor Malls
Grocery Store/Dept. Store (Walmart)
Restaurants
Other Area Not Defined
Offices/Hospitals/PT
Employment/School
Downtown/Urban Area
Movies/Concerts
Sporting Events
Church
Outdoor Fairs/Parades/ Exhibits
Airport
Public Transportation
Car
Rural Area/Campground

Military Status:*

In Which Branch of the Military Did You Serve?*

Ex: Navy, Amy, etc.

Were You Physically Injured In Combat?*

When You Are Having A Tough Time, What Things Do You Do To Distract Yourself, Calm Yourself Down, or Make Yourself Feel Better?*

Have You Ever Been Diagnosed With Any of the Following:*

The Reason I Want A Service Dog Is?*

Do you understand that if you are selected as a PFLK9R client, a one-week training session in one of our training locations will be required? Yes No*

Signature*

Date*

PFLK9R Applicant Background Information Release Authorization

I, First Name* Last Name*, hereby authorize Paws For Life K9 Rescue (PFLK9R) and its designated agents and representatives to conduct a comprehensive review of my background causing an investigative consumer report to be generated for application purposes.

I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas:

Verification of social security number; current and previous residences; employment history including all personnel files; education including transcripts; character references; criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; birth records; motor vehicle records to include traffic citations and registration; and any other public records or to conduct interviews with third parties relative to my character, employment history, and/or general reputation.

I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me to PFLK9R or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.

I hereby release PFLK9R, the Social Security Administration, and its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release. You may contact me as indicated below.

Full Name:   First Name*    Middle Name*   Last Name*

Former Name (if applicable)  First Name   Last Name
Date Last Used:     Date

Former Name (if applicable)   First Name   Last Name
Date Last Used:   Date

Current Address:   Street Address*      City*   State*   Zip*
From:   Date*   To:   Date*

Previous Address:   Street Address*      City*   State*   Zip*
From:   Date*   To:   Date*

Telephone Number:      (000) 000-0000*
Social Security Number:    000-00-0000*       Date of Birth:   Date*
Gender:   Female   Male*
Driver's License Number:  Driver license number*   State Issued:   State Issued*

Have You Ever Been Charged With or Convicted of a Crime?   Yes   No*
If Yes, Please Explain:   If Yes, Please Explain

By signing below, I acknowledge that I have read and understand the above and that the information provided is accurate to the best of my knowledge.

Signature*

Date*

Upload Medical Prescription for a Service Dog & Copy of Military ID Card or DD Form