Rescue 22 Foundation Service Dog Application

Thank you for your interest in receiving a service dog from the Rescue 22 Foundation [R22]. R22 provides fully task trained service dogs to veterans that 1.) demonstrate need as documented by a medical professional and 2.) would benefit from a service dog as a therapeutic tool as part of a comprehensive medical or mental health plan.

Each application is evaluated on its own merits. All information that is requested as part of this application is critical to ensure the best match possible in the selection of your service dog candidate. If you have any difficulty or have any questions for clarification while completing this application, please send an email to info@rescue22foundation.org and we will schedule an appointment via video conference to assist you.

ALL INFORMATION GATHERED AS PART OF THIS APPLICATION IS KEPT STRICTLY CONFIDENTIAL AND WILL NEVER BE SHARED WITH A THIRD PARTY.

To qualify for an R22 Service Dog, you must meet the following criteria (other acceptance criteria may be required upon review):
i) Verifiable and documented diagnosis by a licensed and certified clinician or medical professional;
ii) DD214 demonstrating honorable discharge, medical retirement or retirement from military service;
iii) Stable living environment and the ability to financially support a service dog;
iv) Free of substance abuse;
v) Not have a conviction of any crime against animals.

Documentation Checklist

Completed Application DD214 Medical Professional Letter or other formal documentation of primary diagnosis

Please upload a copy of your DD Form 214 (Member 4 Copy).

Browse Files

Please upload a copy of your Medical or Mental Health Professional Documentation.

Browse Files

Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number

Email

example@example.com

Primary Doctor Name and Contact Information

Psychologist or Mental Health Professional Name and Contact Information

Emergency Contact Name, Relationship, Phone number and email.

Have you ever applied for or been accepted for a service dog by another organization?

Yes No Yes but the dog ended up not meeting my needs.

Have you ever been denied a service dog by another organization?

Yes No

What type of support is available to assist you with the care of a service dog (veterinarian visits, feeding, bathing etc) in the event that you were unable to perform these tasks?

Do I really love dogs enough to have one with me at all times?

Yes, without a doubt. Yes, but I understand that it will still require an adjustment. Maybe I need to think about that a bit more.

Will a service dog still be a good fit for me in five, eight or ten years? Service dogs are bred to work and need a job to thrive. They require ongoing training, mental stimulation and a great deal of physical exercise to keep them strong and healthy. Are you committed to continuing this over the lifespan of your service dog?

I need to think about this. Maybe I am considering biting off more than I can chew. Yes, this will be part of my own healing process and mirrors my current lifestyle.

Am I okay with being visible to the public in another way? Once you have a service dog, the public takes a new interest in you in public places. Sometimes this includes asking inappropriate and invasive questions. Hidden and invisible diagnoses (like PTS or TBI) may even cause business owners or the casual observer to challenge your "need" for a service dog.

Yes, I can handle and accept this aspect of having a service dog. Yes, but I am concerned that it may trigger some anger or anxiety and I will need some coping strategies. Maybe the service dog option will make me more stressed in public and I need to reconsider.

Am I able to accept that utilizing a service dog is a big adjustment, especially in the first few months? Am I willing to be disciplined and consistent with the guidelines provided by the R22 trainer and reach out immediately if I require additional assistance?

Yes, without a doubt! Yes, I am apprehensive of the adjustment but I believe I will succeed. No, this is starting to sound like more trouble than it is worth.

Lastly, I understand that having a service dog is a huge committment. A service dog is not a pet and as such requires a great deal of additional time, effort and energy.

If at anytime you are unable or become unwilling to care for your service dog, the dog MUST BE RETURNED to the Rescue 22 Foundation.

Signature *

Clear

Date

Initials *

Select all medical conditions that apply: *

What is your primary diagnosis for which the service dog is to address?

What are the secondary diagnoses that are also applicable for which the service dog should be prepared to address?

Date of onset of primary diagnosis? *

In your own words, how would having a service dog help you with your medical or mental health diagnoses? *

What are your goals that you would like to achieve with your service dog? *

In your own words, describe how a service dog will assist you in becoming more independent or productive or both, at home and in your communit-please be as specific as possible. *

Please describe what an average day looks like for you. What does your current schedule look like at this time? Please be as specific as possible. *

Alert Tasks

Closing Tasks

Forward Tasks

Leading Tasks

Provision Tasks

Turn on/turn off tasks

Carry Tasks

Drag Tasks

Help Tasks

Mobility Tasks

Pulling Tasks

Interrupt Tasks

Open Tasks

Call tasks

Deliver Tasks

Guide Tasks

Find Tasks

Security/Guarding Tasks

The Rescue 22 Foundation is participating with the University of South Florida's School of Public Health and the Florida State Legislature to gather data in support of service dogs as an accepted alternative therapy for PTS. Would you be interested in receiving more information regarding the pre and post survey?

The information that I have provided is true and represents, to the best of my ability, a true depiction of my medical and mental health needs.

Signature *

Clear

Date *

Date

SERVICE DOG APPLICATION

Am I a good candidate for a service dog?

Medical and Mental Health Information

CUES AND TASKS

Permissions