Dogs Matter Temporary Surrender Application

Temporary Surrender Application

Dogs Matter is currently taking applications only in Texas and surrounding areas due to the high volume of need and available fosters. We hope to be able to offer temporary foster services nationwide soon.
Please fill out the following information if you’re interested in Dogs Matter foster care services for your dog. You must be actively seeking an addiction treatment program (or in recovery) for drugs and/or alcohol. All applicants are handled on a case-by-case basis. Dogs Matter prioritizes clients seeking inpatient treatment up to 90 days. You will receive an email copy of your responses and your information will remain strictly confidential. It can take up to 48 hours before we’re able to respond. Please be patient with us — we receive numerous requests each day. Thank you for taking steps to ensure your dog remains safe during your recovery.
PLEASE NOTE: If you have more than one dog, please fill out an application for each dog. In order to expedite the fostering process, please upload any medical records with photos of your dog below. Or you can email them directly to: info@dogsmatter2.org
About You
Your Name (include dog's name in parenthesis)*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date of Birth
Sex*

MaleFemalePrefer not to answerOther
Race/Ethnicity*
Drug of Choice (check all that apply)*

AlcoholCocaineMethHeroinFentanylMarijuanaBenzosInhalantsOpioidsBarbiturates (ex. sleeping pills)Other
Current Living Situation*

By Myself - Apt/HouseWith Roommates - Apt/HouseWith Family/FriendsSober LivingShelterUnhousedPending EvictionOther
3 months Current Living Situation

By Myself - Apt/HouseWith Roommates - Apt/HouseWith Family/FriendsSober LivingShelterUnhousedPending EvictionOther
6 months Current Living Situation

By Myself - Apt/HouseWith Roommates - Apt/HouseWith Family/FriendsSober LivingShelterUnhousedPending EvictionOther
9 months Current Living Situation

By Myself - Apt/HouseWith Roommates - Apt/HouseWith Family/FriendsSober LivingShelterUnhousedPending EvictionOther
12 months Current Living Situation

By Myself - Apt/HouseWith Roommates - Apt/HouseWith Family/FriendsSober LivingShelterUnhousedPending EvictionOther
What has prompted your need to foster your dog(s)?*

Rehab/In-Patient TreatmentHospitalizationSober LivingRelapseUnhousedOther
How long do you expect to be in treatment and/or sober living?*

1 month3 months6 months9 months1 yr or moreOther
Expected Living Situation After Treatment*

By Myself - Apt/HouseWith Roommates - Apt/HouseWith Family/FriendsSober LivingShelterUnhousedOther
Current Employment Status?*

Full TimePart TimeUnemployedContractor/ Self-employedStudentRetiredDisabilityOther
3 months Current Employment Status?

Full TimePart TimeUnemployedContractor/ Self-employedStudentRetiredDisabilityOther
6 months Current Employment Status?

Full TimePart TimeUnemployedContractor/ Self-employedStudentRetiredDisabilityOther
9 months Current Employment Status?

Full TimePart TimeUnemployedContractor/ Self-employedStudentRetiredDisabilityOther
12 months Current Employment Status?

Full TimePart TimeUnemployedContractor/ Self-employedStudentRetiredDisabilityOther
Household Income?*

No IncomeUp to $24,999$25,000- $49,999$50,000+Prefer not to answer
3 months Household Income?

No IncomeUp to $24,999$25,000- $49,999$50,000+Prefer not to answer
6 months Household Income?

No IncomeUp to $24,999$25,000- $49,999$50,000+Prefer not to answer
9 months Household Income?

No IncomeUp to $24,999$25,000- $49,999$50,000+Prefer not to answer
12 months Household Income?

No IncomeUp to $24,999$25,000- $49,999$50,000+Prefer not to answer
Current Method of Transportation?*

Own carDART/ public transitRide shareWalk/ bikeOther
3 months Current Method of Transportation?

Own carDART/ public transitRide shareWalk/ bikeOther
6 months Current Method of Transportation?

Own carDART/ public transitRide shareWalk/ bikeOther
9 months Current Method of Transportation?

Own carDART/ public transitRide shareWalk/ bikeOther
12 months Current Method of Transportation?

Own carDART/ public transitRide shareWalk/ bikeOther
Are you currently facing legal issues that could impair your ability to reunite your pet (ex. probation, outstanding warrants, DUI, violent offenses)? Note: This information will NOT automatically affect your qualification for our program*

YesNo
Emergency Contact
Emergency Contact Name*

First NameLast Name
Relationship to Owner*
examples: friend, family member, counselor
Emergency Contact Email*
example@example.com
Emergency Contact Phone Number*
Please enter a valid phone number.
Individuals authorized to make decisions about your dog or reclaim your dog on your behalf (include name and contact information)*
Name and contact information
Name of Treatment Facility / Sober Living House / Hospital:*
Name of Facility Contact:*
Facility Contact Phone Number:*
Please enter a valid phone number.
Facility Contact Email:*
example@example.com
Anticipated Treatment Check-in Date*

MonthDayYear
Date
Anticipated Treatment Discharge Date*

MonthDayYear
Date
About Your Dog
Dog Name*
Primary Dog Breed*
Is your dog mixed breed?*

YesNo
Dog Gender*

FemaleMale
Dog Size*

Small (0-20lbs)Medium (21-40lbs)Large (41-65lbs)X-Large (65+lbs)
Dog Weight (approx. lbs)*
Dog Age*

Puppy (0-6 months old)Young (6-18 months old)Adult (up to 7 years old)Senior (7+ years old)
Dog Exact Age*
How long have you legally owned this dog?*

< 2 months3-12 months1-3 years4+ years
How did you acquire your dog?*
Have you tried to find other temporary placement for your dog?*

Yes - Friends/FamilyYes - Animal Control / Animal ShelterYes - Dallas Pets Alive / PASSYes - BoardingYes - Pet SitterNoOther
Who is your dog currently with?*

First NameLast Name
Where is your dog currently located?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How many days can your pet stay there or in another safe environment?
Is your dog spayed or neutered?*

YesNoUnknown
Name, Location, Phone Number, Dates of last vet visit (please include all info you can recall):*
Is your dog house trained?*

YesNoUnknown
Is your dog crate trained?*

YesNoUnknown
Does your pet have any medical issues or conditions?*

YesNoUnsure
Please provide additional details about your pet's special needs:
Does your pet have any moderate to severe behavioral issues?*

YesNoUnsure
Please provide additional details about your pet's behavioral issues:
What is your pet's activity level?*
Does your pet have experience with children?*

YesNoUnknown
Please provide details of your pet's interactions with children:
Does your pet have experience with other dogs?*

YesNoUnknown
Please provide details of your pet's interactions with other dogs:
Does your pet have experience with cats?*

YesNoUnknown
Please provide details of your pet's interactions with cats:
Does your pet have a history of bites or aggression towards human or animals?*

YesNoUnknown
Please provide specifics of bite/aggression (note: this does not automatically affect whether your case is approved or denied)*
I confirm the pet behavior details above to be true and accurate to the best of my knowledge. I understand that providing false or misleading information may result in denial of services or other consequences as outlined by the application. (Note: pets with a history of bite/aggression are NOT automatically denied)*

Clear
Please describe any dietary restrictions for your pet:
Please upload at least 3 recent photos of your pet, at least 1 being a full body shot*

Cancelof
Is your pet up-to-date on shots/vaccinations?*

YesNoUnknown
Pet's Medical Records (if available)

Please upload your pet's medical records to confirm that your pet has been altered, microchipped, and up to date on vaccinations.
Cancelof
What would it mean to you if Dogs Matter is able to find placement for your pet?
How did you hear about Dogs Matter?
AFTERCARE INFORMATION
Dogs Matter Counselor

StephenAngelaAmyTrishShawnaOther
Approved # of Days:
INTAKE NOTES:
Priority/Emergency Situation?

YesNo
Treatment Counselor Name
Treatment Counselor Phone Number
Please enter a valid phone number.
Treatment Counselor Email
example@example.com
Sobriety Date

MonthDayYear
Date
Relapse Date

MonthDayYear
Date
Relapse Date(s) / Notes
Have you experienced any of the following (check all that apply):

BullyingHomelessnessDomestic ViolenceIncarcerationJob LossPhysical AbuseSexual AbuseChildhood AbuseDeath of a SpouseHospitalizationNeglectSerious IllnessSexual AssaultTraumatic GriefWarWitnessing a DeathWitnessing ViolenceTerrorismSchool ViolenceNatural DisastersCar AccidentsBullyingOther
Do you still have your dog?

YesNo - adopted by friend/familyNo - returned to rescue organizationNo - passed awayOther
3 months - Do you still have your dog?

YesNo - adopted by friend/familyNo - returned to rescue organizationNo - passed awayOther
6 months - Do you still have your dog?

YesNo - adopted by friend/familyNo - returned to rescue organizationNo - passed awayOther
9 months - Do you still have your dog?

YesNo - adopted by friend/familyNo - returned to rescue organizationNo - passed awayOther
12 months - Do you still have your dog?

YesNo - adopted by friend/familyNo - returned to rescue organizationNo - passed awayOther
Current Living Situation

By Myself - Apt/HouseWith Roommates - Apt/HouseWith Family/FriendsSober LivingShelterUnhousedPending EvictionOther
Current Employment Status?

Full TimePart TimeUnemployedContractor/ Self-employedStudentRetiredOther
Household Income?

No IncomeUp to $24,999$25,000- $49,999$50,000+Prefer not to answer
Current legal matters (potential restrictions, ex. probation)
Current medical health matters (restrictions to employment, taking care of dog, etc.)
Current mental health matters (restrictions to employment, taking care of dog, etc.)
Recovery care following treatment:
Contract Start Date

MonthDayYear
Date
Contract End Date

MonthDayYear
Date
Dog Visit Date

MonthDayYear
Date
Reunion Date

MonthDayYear
Date
Owner Surrender Adoption Date

MonthDayYear
Date
AFTERCARE NOTES:
DOG/FOSTER NOTES:
Photos/Videos

Cancelof
Total After Care Spent - this is a total of all client's after care expenses
Loss of Contact?

Yes
AGENDA

Yes
Should be Empty:

Temporary Surrender Application

About You

Emergency Contact

About Your Dog

AFTERCARE INFORMATION