Freedom Service Dogs Assistance Dog Inquiry Form FINAL

Freedom Service Dogs Inquiry Form

Complete this form to express interest in our service dog and facility dog programs. Your responses help us understand your needs and eligibility to help us determine if our program might be a good fit for you. Our team will review your inquiry and contact you about next steps.
Date

MonthDayYear
Date
Full Name

First NameLast Name
How would you like to be referred to?
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
City & State
Age
If completing this form on someone else's behalf, please enter their age.
Are you completing this inquiry form for yourself?
If no, please provide your name and describe your relationship with the individual who you are completing the inquiry for.
How did you hear about Freedom Service Dogs?
Have you previously applied for a service dog or facility dog through FSD or another organization?
If yes, when and with which organization?
Are you currently on any other waiting lists?
Which Freedom Service Dogs program are you interested in?
After selecting a program, please fill out the section that matches your selection.
- Are you a veteran or first responder?
- Do you have a PTSD diagnosis from a medical professional?
- Do you have any secondary diagnoses?
- If yes, please list:
- For veterans - are you able to provide proof of service and honorable discharge with a DD214 (member 4 copy)? For first responders - are you able to provide proof of employment as a first responder?
- What is your primary diagnosis that you would need a service dog to help with?
- Do you have any secondary diagnoses?
- If yes, please list:
- Do you have an autism diagnosis from a medical professional?
- Do you have any secondary diagnoses?
- If yes, please list:
- What is your job title?
- In what type of facility do you work?
- Please describe the population you work with:
- Briefly describe how you would like a facility dog to assist you with your work.
- Briefly describe what you would like an assistance dog to assist you with.
- What tasks are you hoping an assistance dog could perform to mitigate the symptoms of your disability?
- Will you require a dog to assist you in accessing public places? (e.g., grocery store, concerts, etc.)
- Do you anticipate any upcoming major changes in your life? (e.g., moving, new job, surgeries, etc.)
- If yes, please describe your upcoming change(s).
- Do you have any pets in the home?
- If yes, please list how many and what type of animal?
- When are you hoping to receive an assistance dog?
- Do you have a support person/community (family member, caregiver, partner, day programs etc.) who can assist you if needed?
- If yes, please describe their role.
- An assistance dog can assist with many things, however, they are not a cure or quick fix and require ongoing care and engagement. Do you currently have the capacity to care for a dog and maintain the training of an assistance dog?
- Living and working with a dog includes sensory experiences, such as drool, shedding, treat dust, licking, odors, and close contact. What reactions, if any, do you have in response to these experiences?
- What made you interested in an assistance dog at this time in your life?
- Is there anything else you’d like us to know as we review your inquiry?
- What questions do you have about receiving an assistance dog?
- FSD requires background checks on all applicants and anyone living in the household that is over the age of 18. Is there anything in your, or other household members’, criminal history (e.g., arrests, charges, or convictions) that you would like to disclose or provide context for?
- FSD requires monthly and annual reports to be submitted digitally. Is this something you are able to complete?
- I understand that if I were to receive an FSD Service Dog, I would need to travel to Colorado for a match meeting and 2 weeks of on-site training with my new dog. For an FSD Facility Dog, I would need to travel to Colorado for a match meeting and 1-2 weeks of on-site training with my new dog.
- I understand that if I were to receive an FSD Service or Facility dog, I would need to travel to Colorado a minimum of 5 times AFTER placement for travel for recertification tests.
- I understand this inquiry form does not guarantee acceptance into the Freedom Service Dogs program.
- I give permission for Freedom Service Dogs to contact me regarding next steps.
- What is the best way to reach you?
Thank you for you interest in an asssistance dog with Freedom Service Dogs.

Due the to the length of our waitlist, we are currently not accepting inquiries for mobility or austim assist service dogs. We recommend you do further research on other service dog organizations at Assistance Dogs International (ADI). ADI is a worldwide coalition of non-profit organizations that provide assistance dogs to individuals in need. www.assistancedogsinternational.org.
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Freedom Service Dogs Inquiry Form