P.E.T.S. Network Request for Service Form

  • P.E.T.S. Network Request for Service Form

  • Format: (000) 000-0000.
  • Is it okay to leave a message?*
  • Please indicate if you have qualified for any of the following.
  • Are you a veteran?*

  • Occupation Information

  • Format: (000) 000-0000.

  • Secondary Contact Information

  • Format: (000) 000-0000.

  • Agency Information

    We require the participation of a third party social services agency for all Domestic Violence clients. For any other situations this information is preferred.
  • Format: (000) 000-0000.

  • Emergency Details

  • Which of the following best describes why you are applying for this program?*

  • ***If this is a Domestic Violence case please also answer the following questions:

    (If you need resources for Domestic Violence please click HERE) :

  • Are your pets included in a restraining order/or emergency protection plan?
  • If yes, can you provide a copy of the restraining order?
  • Date Order Granted
     - -
  • Do you think the abuser will try to find the animal(s)?
  • Does the abusive person have any legal claim to the animal(s)?
  • Has the abuser, or anyone in your home, ever threatened, injured, or killed any of your animal(s)?

  • Additional Information

  • Are you able to proof of animal(s) ownership?*
  • Which of the following resources have you exhausted before completing this application? Select all that apply.*
  • Do you understand that admitting your animal(s) into our care may be stressful and/or expose them to diseases that may have an adverse effect on them both mentally and physically?*
  • In the event of behavioral deterioration, do you agree to pick up your animal should HSWM staff and/or the P.E.T.S. Foster Parent deem the animal(s) not safe to handle?*
  • Do you consent to having your animal(s) spayed or neutered, microchipped and updated on required vaccines if the procedure has not already been performed or you cannot provide proof?*

  • *HSWM highly recommends that all costs are covered by the owner at the time of animal(s) admittance into P.E.T.S. Network

  • Will you have regular access to your phone or e-mail to check-in with the Community Resource Coordinator on a weekly basis? (*Clients who miss two consecutive check-ins and/or whose phones become disconnected will forfeit their use of this program; after two weeks of no owner contact the animal(s) are considered owner relinquished and may be placed up for adoption after the contract’s expiration).*
  • If your pet is admitted into the program, do you understand that you may lose your ability to utilize this program again in the future?*
  • Can you commit to pick-up your pet(s) within 24 hours of your signed contract’s expiration?*

  • *Animals whose owners do not make pick-up arrangements in a timely manner are subject to being considered owner relinquished and may be placed up for adoption after the contract’s expiration.

  • Animal Information (this information will be scanned into our database).

  • Has your pet bitten and broken skin on someone within the past 10 days?*
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  • *Animals must be at least 8 weeks old or accompanied with their biological mother to participate in P.E.T.S. Network. 

  • Pets Medical Information

  • Format: (000) 000-0000.
  • Is this animal currently up to date on their vaccinations?*
  • Can you provide proof of up-to-date vaccine records for your animal?*
  • Can you provide proof of a negative heartworm test within the last year?*
  • Last date heartworm preventative as given?
     - -
  • Last date flea/tick preventive was given?
     - -

  • *HSWM is unable to accept controlled medications for animal(s) for P.E.T.S. Network. HSWM a licensed veterinarian will re-prescribe controlled medications as deemed necessary.

  • Is this animal spayed or neutered?*
  • Can you provide proof of spay/neuter procedure for your animal?*
  • Is this animal microchipped?*
  • If your animal is microchipped can you provide proof that the microchip is registered to you (if your pet is registered to another person we legally will have to contact them)?*

  • Pet's Feeding Information

  • What type of food does this pet eat?*
  • If your pet has dietary restrictions will you be able to provide their food?

  • Lifestyle & Behavior Information

  • Present housing situation*
  • Is your pet house trained or litter box trained?*
  • Is your pet crate trained?*
  • Will your pet chew or scratch furniture, clothing, or doors when left unattended?*
  • Activity level*
  • Does your pet know any of the following cues?*
  • Is your pet afraid of any of the following?*
  • What is your pet's reaction when they are afraid, select all that apply.
  • Has your pet successfully lived with other animals?*
  • Has your pet ever bitten or scratched a person?*
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