Psychiatric Service Dog Application

Program Trained Service Dog Application

We are only accepting applications for fully trained Psychiatric Service Dogs through this application.

If you are interested in training your own dog as a service dog, please visit our 'Owner Trained Service Dogs' page.
All applicants will be considered, regardless of race, sex, religion, creed, sexual orientation and ethnic origin.
Unless otherwise noted, please provide applicable information for prospective Service Dog Handler.
Please be aware that acquiring a Service Dog is a large financial commitment up to $30,000. If we find a match that we believe will meet your needs, we will discuss the details of your specific situation and what the exact cost of your service dog will be.

Have you been in therapy for at least 1 year?

Are you aged 12 - 26 years old?

Do you have a psychiatric disability as defined by the ADA?

Preferred Name

First NameLast Name

Preferred Pronouns

Date of Birth

MonthDayYear

Parent or Guardian if applicant is a minor

Address

Street Address

Street Address Line 2

CityState

Zip Code

Email

example@example.com

Mobile Phone

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Name

Emergency Contact Phone

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Email

example@example.com

Emergency Contact Relationship

Include Emergency Contact in Emails?

Name of Therapist/Doctor managing diagnosis

Therapist/Doctor's Phone

Please enter a valid phone number.Format: (000) 000-0000.

Therapist/Doctor's Email

example@example.com

Have you discussed this with your doctors?

Have you discussed this with your family or caregivers?

Letter from your doctor/therapist is optional for the application but is required for our final decision. If a letter is not attached to the application, we will contact you for this prior to final approval. Letter must confirm that applicant:
(1) is disabled as defined by ADA
(2) has been in therapy for at least one year - has a proper support system in place for working with and caring for a dog.

Upload Doctor/Therapist letter here:

Have you ever served in the military?

Occupation / Former Occupation

Do you own or rent?

Do you have a fenced in yard or other way to provide exercise?

Is anyone in your home allergic to dogs?

Have you ever had a dog before?

Tell us about your experience with dogs.

Tell us a little about your support system.

Do you use a local vet?

Current Vet contact info

Do you have other dogs in your home?

Please list any other pets in the home:

Does anyone in your home smoke?

Are there any guns in your home?

If yes, will you take your dog to the shooting range?

What are your hobbies?

What is your current disability diagnosis?

Were you diagnosed more than one year ago?

Explain briefly how your disability affects your life and current level of independence.

How does your disability impact your education?

Provide a brief history of your disability. Do not include abbreviations or initials when discussing your disability.

Will you have time to spend with a dog?

Number of hours a day your service dog will be alone?

Will you be able to clean up after your dog goes to the bathroom?

Will you be able to take your dog to the vet?

Will you be able to groom your dog?

What types of transportation do you use? Select all that apply

Will your service dog accompany you on vacation?

Will your service dog accompany you to work or school?

What specific needs or services do you feel a service dog can provide for you?

If I get approved to receive a service dog from The Exceptional Sidekick, I agree to travel to Newtown, CT for weekly team training classes for up to one year, based on assessed need by The Exceptional Sidekick's trainers.

I understand that the estimated yearly cost of caring for a service dog is roughly $2,500 and I understand that I am responsible for those expenses and obtaining medical insurance for my dog.

I understand that if I am approved for a service dog from The Exceptional Sidekick, I will be subject to a criminal background check prior to the dog being placed in my care.

I understand that applying for a service dog does not guarantee the placement of a service dog.

Applicant Eligibility Attestation

Application Acknowledgement:

* You have the right to withdraw your application at any time for any reason, without penalty.

Please verify that you are human

Process Manager