Form
Veterans Service Dog Society of Alberta Application
Back
Next
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Do you believe your income is stable and expected to continue for the duration of having a Service Dog?
What is your average household income? This is to determine if you will financially be able to maintain a Service Dog for the duration of its life.
Please Select
under $50,000
between $50k - $100k
Over $100,000
Back
Next
Do you have a support system (or several) in place who encourages and compliments the decision to seek a Service Dog. Choose all that apply.
Veteran Affairs Canada
Family / Spouse
Friends
Legion
Veteran groups / clubs
Counsellor
Where to you feel most of the support for this decision will come from?
Back
Next
Have you been diagnosed with PTSD (or similar mental health diagnosis) by a medical licensed provider?
Please Select
Yes
No
Is your medical provider prepared and willing to write a prescription for a Service Dog? If you already have one, please attach at the end.
Please Select
Yes
No
Is your medical provider prepared and willing to fill out forms for the Government of Alberta when it is time for final assessment of yourself and the Service Dog?
Please Select
Yes
No
Back
Next
How does PTSD impact your daily functioning? Please explain in brief or in detail depending on how much you want to share, but please give some examples so we understand your need for a service dog.
How do you believe a Service Dog will help you mentally, physically or emotionally?
Back
Next
How often do you experience hypervigilance or the inability to feel safe in public?
Please Select
not often
often
very often
How frequent to you experience panic attacks or flashbacks?
Please Select
Rarely
Sometimes
Frequently
Do you suffer from nightmares or night tremors?
Please Select
Yes
No
Do you disassociate or shut down emotionally?
Please Select
Rarely
Frequently
Constantly
Back
Next
How do you feel a Service Dog would improve your daily life?
Back
Next
Taking on a Service Dog requires training attendance and training upkeep, some will be private and some will be group sessions, are you willing to attend the necessary session to complete the training as a team with your potential Service Dog to be completely prepared for the final assessment with the Government of Alberta?
Please Select
Yes
No
Did you know and are you prepared to take your Service Dog everywhere, examples are doctors offices, dentist offices, gatherings, meeting, road trips, grocery shopping, etc.?
Please Select
Yes
No
Have you owned a dog in the past?
Yes as a child
Yes as an adult
Never
Do you currently have other animals in your home? Please list.
Back
Next
Please let us know your living arrangements currently.
Please Select
Long term rental - apartment
Long term rental - house (yard)
Own residence
Temporary housing
If you are a renter, does your landlord know and support a Service Dog?
Please Select
Yes
No
What age of Service Dog are you looking for?
Please Select
Puppy (8-12 weeks old)
Almost 2 (trained but not certified)
I have a dog to be trained
If you have chosen 'puppy' in the above question, this suggests you are aware of the typical dog training required, (potty training, chewing, etc) and are you prepared and comfortable with this. Having a dog from the puppy stage does allow for a deeper bond between the handler and dog but does require a bit more work.
Please Select
Yes
No
N/A
Please upload if you have a prescription for a service dog. This can also be obtained at a later date. Please also upload military veteran ID.
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: