Questionnaire
How did you hear about SDA?
Social Media
News/Newspaper
A Service Dog Recipient
SDA Event
Search Engine (Google)
What type of dog do you need?
*
Service Dog
Companion Support Dog
Facility Dog
I am a:
*
Veteran
Child's Guardian
Adult
Other
Child/Youth section
Can all adults in the household pass a criminal background check?
*
Yes
No
Do you live within 175 miles of Montgomery, Alabama?
*
Yes
No
Do you agree to attend all required training?
*
Yes
No
You do not qualify to apply for a Service Dog at this time.
You qualify to apply for a Service Dog. Please download this document, complete it, and mail it to the address provided.
Adult Service Dog section
Can all adults in the household pass a criminal background check?
*
Yes
No
Do you live within 175 miles of Montgomery, Alabama?
*
Yes
No
Do you agree to attend all required training?
*
Yes
No
Do you have a fenced-in yard attached to your home?
*
Yes
No
You do not qualify to apply for a Service Dog at this time.
You qualify to apply for a Service Dog. Please download this document, complete it, and mail it to the address provided.
Facility Dog section
Is the handler a full-time employee?
*
Yes
No
Does the handler commit to bringing the dog to work everyday?
*
Yes
No
Does the handler commit to attend five (5) days of training at the time of the Facility Dog's placement?
*
Yes
No
Does the handler commit to attend two (2) days of training for recertification for three (3) years after receiving the Facility Dog?
*
Yes
No
Does the handler commit to keeping the dog clean and groomed?
*
Yes
No
Does the handler commit to learning and practicing the principles of Follow the Lead?
*
Yes
No
Does the handler commit to completing and returning all surveys and required updates to Service Dogs Alabama?
*
Yes
No
Is there a fenced in yard attached to the house?
*
Yes
No
Are there more than three (3) pets in the home?
*
Yes
No
Are there any aggressive animals in the home?
*
Yes
No
Are there any children under the age of four (4) years old?
*
Yes
No
Is the environment in the home low-stress?
*
Yes
No
Is the interior and exterior of the home free of poisonous items?
*
Yes
No
Is the interior and exterior of the home free of choking hazards?
*
Yes
No
You qualify to apply for a Facility Dog!
You do not qualify to apply for a Facility Dog at this time.
Companion Support Dogs Section
Do you have a recommendation from your doctor for a Companion Support Dog?
*
Yes
No
Do you agree to attend required training?
*
Yes
No
Do you have a fenced yard attached to your home?
*
Yes
No
Is your home free of choking or poisonous hazards that could harm your dog?
*
Yes
No
A Companion Support Dog does NOT have Public Access. Do you agree not to fake that your CSD is a Service Dog to gain Public Access and / or privileges?
*
Yes
No
A Companion Support Dog is for in-home assistance only and does NOT have Public Access. Do you need an CSD for at home use only?
*
Yes
No
You qualify to apply for a Companion Support Dog!
You do not qualify to apply for a Companion Service Dog at this time.
Veteran Section
We provides service free of charge to the Veteran (this includes all room and board as it pertains to required training and recertification).We place trained and certified Service Dogs for various physical and phsychological disorders.
Name
First Name
Last Name
Email
example@example.com
DOB
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Cell
Please enter a valid phone number.
Work
Please enter a valid phone number.
Height
Weight
Military Branch and Rank
If you were deployed, please list where
Years Enlisted
Current Status
Active
Medically Discharged
Retired
Medical Diagnosis
Employment Status
Full Time
Part Time
Retired
Student
Medically Disabled
If employed or a student, please list where
How long have you been employed/a student here?
Have you discussed a service dog with your employer?
Yes
No
N/A
If yes, what was their response?
Are you prepared for the time and financial commitment of a Service Dog?
Yes
No
What is your annual household income?
Is this income stable?
Yes
No
Diagnosis
What is your primary diagnosis?
Are there additional medical problems?
What medications do you currently take?
How does this affect your daily living skills?
Are there any restrictions or precautions as a result of your diagnosis?
What type of medical treatment equipment do you use? (i.e. wheelchair, hearing aid)
Have you had any dissociative episodes in the past?
Yes
No
If yes, what triggered the episode?
Do you drink alcoholic beverages?
Yes
No
If yes, how many drinks per day?
Do you have a history of alcohol or drug abuse?
Yes
No
If yes, are you currently seeing a mental health provider that you have seen for more than 12 months?
Yes
No
N/A
If yes, where are you in treatment?
Spouse Information
Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Cell
Please enter a valid phone number.
Work
Please enter a valid phone number.
Employment Status
Full Time
Part Time
Retired
Student
Medically Disabled
If employed or a student, where?
How long have you been employed/a student there?
Do you have issues with anger?
Yes
No
If yes, please explain
Have you or a family member ever been arrested?
Yes
No
If so, what was the charge?
Were you convicted?
Yes
No
N/A
If yes, please explain
What type of home do you live in?
Apartment
Home
Do you rent or own?
Rent
Own
Do you have a fenced in yard?
Yes
No
If not, do you plan to fence in the yard?
Yes
No
N/A
Please list all those living in your home with you (include name, age, and relationship to you
Are there any pets currently in the household?
Yes
No
If yes, please list the type/breed of each
Are they spayed/neutered?
Yes
No
N/A
Do they live inside or outside?
Inside
Outside
If there is an issue with one of your pets and your new Service Dog, are you prepared to re-home that pet?
Yes
No
N/A
Do you agree to attend all required trainings with your Service Dog?
Yes
No
Service Dog Information
Most of our Service Dogs are Labrador Retrievers. Is this breed a good match for you?
Yes
No
What tasks do you think a service dog could do to make you more independent?
Other than performing tasks, how do you think a Service Dog can help you?
Submit
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