Evaluation

Evaluation Request

To request an evaluation of your dog, please fill out and submit the form below. We will contact you within 2 business days to set up an Evaluation appointment. **There is a $50 fee for evaluations which will be credited back to the purchase of any training program. Payment is required to hold the Evaluation time slot and is non-refundable. We understand life happens, so one re-schedule is allowed! We are looking forward to working with you!
About You
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Not including yourself, how many people live in your home?*
Ages?*
Do you have a fenced-in yard?*

YesNo
Do you have any other pets?*

YesNo
Explain*
E-mail*
Best Phone Number*

Area CodePhone Number
Birthday*

MonthDayYear
Are you employed?*

YesNo
Where?*
What (if any) equipment do you use?*

Manual WheelchairElectric WheelchairCaneWalkerHearing AideCrutchesProsthesisBraceNone
How did you hear about us?*

FriendInternet SearchFacebookVeterinarianOther
About Your Dog
Name*
Breed*
Gender*

MaleFemale
Dog Birthday*

MonthDayYear
Spayed/Neutered?*

YesNo
Spay/Neuter Date*

MonthDayYear
How long have you owned the dog?*
Where does the dog sleep?*
Is the dog allowed on furniture?*

YesNoSometimes
What furniture and when?*
Have you worked with dogs before?*

YesNo
Describe in detail: when, where, how long*
Have you recieved training with this dog before?*

YesNo
Describe the dog's daily activities*
Describe in detail: when, where, how long*
Are you seeking to have your dog assessed for service dog training?*

YesNo
Please describe the nature of your disability. All answers will be confidential*
Has your disability been diagnosed through a medical professional?*

YesNo
When?*

MonthDayYear
Date
Name of Diagnosis*
Please explain:*
It is necessary to have a letter from your attending medical professional indicating that a service dog would be beneficial for your diagnosed disability. Are you able to provide this letter?*

YesNo
Please explain:*
What tasks do you need your dog to be able to perform?*
Are you a veteran?*

YesNo
Branch:*
Years of service:*
Can you provide a DD-214?*

YesNo
Please explain:*
Please select YES or No for each option below

Does your dog have problems with...
Excessive Barking*

YesNo
Explain*
Chewing*

YesNo
Explain*
House-Breaking*

YesNo
Explain*
Digging*

YesNo
Explain*
Jumping*

YesNo
Explain*
Running Away*

YesNo
Explain*
Chasing*

YesNo
Explain*
Mouthing*

YesNo
Explain*
Food or Toy Possesive*

YesNo
Explain*
Dog Aggression*

YesNo
Explain*
People Aggression*

YesNo
Explain*
Other undesireable behavior*

Rate how well the dog listens*

	1	2	3	4	5	6	7	8	9	10

1 is Does NOT Listen, 10 is Extremely Responsive

What are your specific goals for training with your dog?*
Should be Empty:

Evaluation Request

About You

About Your Dog