Helping Paws Letter of Interest Form
Helping Paws places service dogs with: individuals who have physical disabilities, other than the loss of sight or hearing veterans and first responders affected by PTSD. We are unable to place service dogs for autism, for seizure or diabetic alert, or to assist with the management of mental illness as a primary condition.
Area of Interest
Please Select
I have a physical disability
I am a veteran affected by PTSD
I am a first responder affected by PTSD
I work at a facility and am interested in applying for a facility dog
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
Tell us about your disability
Tell us how you feel a service dog will help you in your daily living. List specific tasks you would like a service dog to perform.
Do you have Alzheimer's or Dementia?
Please Select
Yes
No
Do you have a disability that causes significant memory loss or cognitive impairment?
Please Select
Yes
No
Do you live in a group home, assisted living facility or nursing home?
Please Select
Yes
No
Is there a reasonable expectation that your medical situation will allow you to use and benefit from a service dog's skills for 8+ years?
Please Select
Yes
No
How many hours per day do you spend in bed?
Additional Comments:
Facility Name
Facility Street Address
Facility City
Facility State
Facility Zip
Tell us about your job.
How would you like to utilize a facility dog?
Do you have approval to utilize a facility dog from your employer?
Please Select
Yes
No
Additional Comments:
Branch of Service
Are you currently on active duty
Please Select
Yes
No
Select Option Yes NoList deployments; operation, country, dates
Discharge Status
Service Connection Rating
Do you have a physical disability?
Please Select
Yes
No
Tell us how your PTSD affects you.
Are you currently receiving therapy? If so, what services are you using?
Tell us how you feel a service dog will help you in your daily living. List specific tasks you would like a service dog to perform.
Do you have any experience with service dogs? If yes, please explain.
How did you hear about Helping Paws?
Are you or were you ever employed as a First Responder?
Please Select
Yes
No
Do you have service connected PTSD?
Please Select
Yes
No
What service field is your service connected PTSD from?
Please Select
Fire Department
Law Enforcement
EMS
Corrections
Dispatch
Do you have a physical disability?
Please Select
Yes
No
Tell us how your PTSD affects you.
Are you currently receiving therapy? If so, what services are you using?
Tell us how you feel a service dog will help you in your daily living. List specific tasks you would like a service dog to perform.
Do you have any experience with service dogs? If yes, please explain.
How did you hear about Helping Paws?
Submit
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