NewLifeK9s-AssistanceDogApplication

Service Dog Application
Dear Prospective client,

Thank you for your interest in being matched with one of our incredible service dogs! Please read the instructions carefully, we cannot process applications until we have recieved all of the required information. In order for New Life K9s to continue best serving its mission, applications must be completed within 90 days of the start of the process. Our client services specialists will do his/her best to accomodate every applicant's needs throughout the process, however, if your application is incomplete after 90 days, it will be removed from the waiting list. If you have any questions about the application process please email us at newlife@newlifek9s.org

Before you get started

Please note that a completed application includes the following:
1. Your photo (within the last year)
2. The copy of your DD214 (Veterans) or proof of duty (First Responders)
3. The completed Assistance Dog Application (this form)
4. The Consent to Contact and Authorization form identifying any relevant health providers we may need to contact for information on your need for a service dog
5. The Applicants Medical History form, which is available for download on the New Life K9s website. The form must be completed by your current physician or primary care specialist and returned by the physician DIRECTLY to New Life K9s by email, fax, or snail mail.
6. The Applicants Mental Health Medical History form, which is available for download on the New Life K9s website. The form must be completed by the professional overseeing your mental health treatment.
7. A personal letter of reference from a friend, teacher, or family member explaining how they see you benefitting from a service dog.
8. A professional letter of reference from a therapist, social worker, teacher, or any other professional with whom you have contact explaining how they see you benefitting from a service dog.
9. A one-page letter stating your reasons for wanting a service dog and how you feel the dog would benefit you.

Application Steps
Step 1: Complete the application

Step 2: Preliminary Acceptance and Addition Paperwork

After a succesful application review by our staff, the next step in the process is to have seven social style forms completed on your behalf by people you select. Once we recieve all the social styles forms we will add you to our interview waitlist.

Step 3: Interview and Follow-Up

We will contact you to schedule an interview with staff. If you are unable to travel to our campus, we will arrange to conduct the interview via video conference. The interview is the final step in the process that enables us to determine if our service dogs are able to meet your needs. After the interview, we may conduct further follow-up with providers and family members. During this time, you will be on our waitlist. *Note: there will be quarterly follow-up with staff to update the application after acceptance to the waitlist in order to keep all information up to date.

Step 4: Final Acceptance

If your application is accepted after the interview, we will notify you approximately 2-4 weeks after the interview. If you are selected for placement, please understand that it may take more than 2 years to match a client with a dog due to the high demand for assistance dogs and the necessity of matching each dog carefully to the personality and needs of each client.

Step 5: Match and Placement

Once a potential match has been determined, you will be invited to attend the two-week Assistance Dog Client Training course held in San Luis Obispo, CA. The course will be held at our training facility as well as at the prison where the dog was taught. The class will culminate in a graduation ceremony where your dog will be formally transferred from the dog's inmate handler, who has been caring for the dog, to you. While attending this training, our Campus/Prison Rules will apply to you. Please note that New Life K9s is located on a "no smoking" campus. The related expenses you will need to plan for are: transportation, food, movies, housing, ect. while attending the training course. Once you graduate with your dog, you will be responsible for the ongoing costs of caring for your new partner, including: food, grooming, and veterinary expenses.

Ongoing Support

Once a dog is placed with you, we provide ongoing support for the remainder of the working partnership. We work in partnership with you to support the dog's health, behavior, temperament, and training through written, phone, video, and in-person follow-up. We have a staff member dedicated to client services available to communicate with you whenever you need advice, and we have training staff that are ready to consult with you and support your needs on an ongoing basis.

At a minimum, we proactively reach out for regular follow-up every month for the first 6 months of placement, at 9 months, and then annually thereafter. The annual report will require a veterinary health report and ADI Public Access Test completed with a New Life K9s staff member or trained volunteer.

In addition, we are proud to offer our clients the oppurtunity to become full owners of their dog, depending on the specifics of each case. We also know that when a dog approaches retirement, it can be an uncertain and stressful time for our clients, so we give priority to our existing clients who seek a succesor dog when their dog approaches retirement.
Please note: This application must be completed by the applicant or answered under the direction of the applicant. Questions in the application are our only source of information by which we can ensure that we are prepared to best meet the needs of our applicants.

If you are unable to complete this application at one time, click the button at the bottom of the screen to save the application and send yourself a copy to your email so you don't have to start over at the beginning.

General Information About You
Name*

First NameMiddle NameLast Name
Upload a recent photo of you here:

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Please upload a copy of your DD214 or current official department identification card

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Height *
*This will help us to place you with the proper sized dog
Weight (pounds) *
*This will help us to place you with the proper sized dog
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Sex*

MaleFemalePrefer Not to AnswerOther
Emergency Contact Information
Emergency Contact*

First NameLast Name
Relationship to Emergency Contact*
Emergency Contact Number*

Area CodePhone Number
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employment Information
Current or Most Recent Place of Employment*
Employment Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number

Area CodePhone Number
Personal Information
Marital Status*
With whom do you live? (check all the apply)*

AloneWith parentsWith spouse or significant otherWith attendantWith roommatesOther
Where do you live?*

HouseApartmentDormOther
Do you rent or own the property?*

RentOwnOther
Please list your landlord's name and contact information.*
How long have you lived in your current housing?*
Are there any young children in your life?*

I live with children.I have children who visit regularly.No
How old are the children?
Your living situation has...*

a fenced yardan enclosed outdoor areano private outdoor spaceoutdoor area that is not fenced
Would you agree to a home visit from us before placement?*

YesNo
Please list all members of your household. *
Describe your home atmosphere (check all that apply):*

QuietModerately NoisyVery NoisyHigh EnergyMainly Just FamilySome VisitorsMany Visitors
Do you have any criminal history, been on parole or probation, have any pending charges or charged with driving under the influence?*
Do you understand that a service dog is a living animal and will require ongoing training to keep up on their skills?*
Do you understand that a service dog is an additional assistance and not a cure/treatment itself?*
Do you accept that the use of a service dog will publicly identify you as a person with a disability?*
Are you able to travel to the New Life K9s facility in San Luis Obispo for your interview and bootcamp?*
Medical Information
Primary Disability*
Age at Diagnosis*
Cause of Disability (if known)
Secondary Disability / Other Medical Conditions
How many hours of attendant care do you receive each week?*
Please indicate any special instruction / consideration related to your disability / medical conditions (for example hyperreflexia management, seizure precautions, etc.)
Please list any medications, including medical marijuana, you are currently taking:*
Have you participated in an inpatient or outpatient mental health program?*
Motor Impairments
Weakness...*

0 - non-applicable1 - mild2 - moderate3 - severeOther
Spasticity...*

0 - non-applicable1 - mild2 - moderate3 - severeOther
Coordination...*

0 - non-applicable1 - mild2 - moderate3 - severeOther
Sensory Impairments
Vision...*

0 - non-applicable1 - mild2 - moderate3 - severeOther
Hearing...*

0 - non-applicable1 - mild2 - moderate3 - severeOther
Loss of Sensation...*

0 - non-applicable1 - mild2 - moderate3 - severeOther
Cognitive Impairments
Attention...*

0 - non-applicable1 - mild2 - moderate3 - severeOther
Memory...*

0 - non-applicable1 - mild2 - moderate3 - severeOther
Problem Solving...*

0 - non-applicable1 - mild2 - moderate3 - severeOther
Judgement...*

0 - non-applicable1 - mild2 - moderate3 - severeOther
Communication Impairments
Comprehension...*

0 - non-applicable1 - mild2 - moderate3 - severeOther
Expression...*

0 - non-applicable1 - mild2 - moderate3 - severeOther
Psychological / Behavioral Descriptions
My depression is...*

0 - non-applicable1 - mild2 - moderate3 - severe
I have an impaired self-esteem that is...*

0 - non-applicable1 - mild2 - moderate3 - severe
My sense of hopelessness or helplessness is...*

0 - non-applicable1 - mild2 - moderate3 - severe
I have appetite disturbance that is...*

0 - non-applicable1 - mild2 - moderate3 - severe
My suicidal ideation is...*

0 - non-applicable1 - mild2 - moderate3 - severe
My isolation is...*

0 - non-applicable1 - mild2 - moderate3 - severe
My lack of empathy is...*

0 - non-applicable1 - mild2 - moderate3 - severe
My panic attacks are...*

0 - non-applicable1 - mild2 - moderate3 - severe
My hyper-vigilance is...*

0 - non-applicable1 - mild2 - moderate3 - severe
My anxiety is...*

0 - non-applicable1 - mild2 - moderate3 - severe
My emotional numbness / detachment / restricted affect is...*

0 - non-applicable1 - mild2 - moderate3 - severe
I have a sleep disorder that is...*

0 - non-applicable1 - mild2 - moderate3 - severe
My nightmares, flashbacks, or intrusive thoughts are...*

0 - non-applicable1 - mild2 - moderate3 - severe
My impulsivity is...*

0 - non-applicable1 - mild2 - moderate3 - severe
I have an exaggerated startle response that is...*

0 - non-applicable1 - mild2 - moderate3 - severe
My irritability or anger control issues are...*

0 - non-applicable1 - mild2 - moderate3 - severe
Please describe any substance abuse history you have.*
Additional Medical Conditions
Please check any of the following medical conditions that apply to you.*

Cardiovascular diseaseRespiratory diseaseDiabetesNeurogenic bladderChronic painSeizure disorderNeurogenic bowelNoneOther
Do you use any of the following assistive devices?*

Manual wheelchairPower wheelchair/scooterWalkerCaneCrutchesOrthosisProsthesisHearing aidOther
Please identify Functional Independence Measure (FIM) levels for the following motor activities.
Self-Care: Eating*

7 Complete independence (timely, safely)6 Modified independence (device)5 Supervision4 Minimal assistance (you can perform 75% of activity)3 Moderate assistance (you can perform 50% of activity)2 Maximal assistance (you can perform 25% of activity)1 Total assistance (you can perform 0% of activity)
Self-Care: Grooming*

7 Complete independence (timely, safely)6 Modified independence (device)5 Supervision4 Minimal assistance (you can perform 75% of activity)3 Moderate assistance (you can perform 50% of activity)2 Maximal assistance (you can perform 25% of activity)1 Total assistance (you can perform 0% of activity)
Self-Care: Bathing*

7 Complete independence (timely, safely)6 Modified independence (device)5 Supervision4 Minimal assistance (you can perform 75% of activity)3 Moderate assistance (you can perform 50% of activity)2 Maximal assistance (you can perform 25% of activity)1 Total assistance (you can perform 0% of activity)
Self-Care: Toileting*

7 Complete independence (timely, safely)6 Modified independence (device)5 Supervision4 Minimal assistance (you can perform 75% of activity)3 Moderate assistance (you can perform 50% of activity)2 Maximal assistance (you can perform 25% of activity)1 Total assistance (you can perform 0% of activity)
Self-Care: Dressing-Upper Body*

7 Complete independence (timely, safely)6 Modified independence (device)5 Supervision4 Minimal assistance (you can perform 75% of activity)3 Moderate assistance (you can perform 50% of activity)2 Maximal assistance (you can perform 25% of activity)1 Total assistance (you can perform 0% of activity)
Self-Care: Dressing-lower Body*

7 Complete independence (timely, safely)6 Modified independence (device)5 Supervision4 Minimal assistance (you can perform 75% of activity)3 Moderate assistance (you can perform 50% of activity)2 Maximal assistance (you can perform 25% of activity)1 Total assistance (you can perform 0% of activity)
Self-Care: Sphincter Control Bladder Management*

7 Complete independence (timely, safely)6 Modified independence (device)5 Supervision4 Minimal assistance (you can perform 75% of activity)3 Moderate assistance (you can perform 50% of activity)2 Maximal assistance (you can perform 25% of activity)1 Total assistance (you can perform 0% of activity)
Self-Care: Bowel Management*

7 Complete independence (timely, safely)6 Modified independence (device)5 Supervision4 Minimal assistance (you can perform 75% of activity)3 Moderate assistance (you can perform 50% of activity)2 Maximal assistance (you can perform 25% of activity)1 Total assistance (you can perform 0% of activity)
Self-Care: Transfer Chair & Wheelchair*

7 Complete independence (timely, safely)6 Modified independence (device)5 Supervision4 Minimal assistance (you can perform 75% of activity)3 Moderate assistance (you can perform 50% of activity)2 Maximal assistance (you can perform 25% of activity)1 Total assistance (you can perform 0% of activity)
Self-Care: Toilet*

7 Complete independence (timely, safely)6 Modified independence (device)5 Supervision4 Minimal assistance (you can perform 75% of activity)3 Moderate assistance (you can perform 50% of activity)2 Maximal assistance (you can perform 25% of activity)1 Total assistance (you can perform 0% of activity)
Self-Care: Tub & Shower*

7 Complete independence (timely, safely)6 Modified independence (device)5 Supervision4 Minimal assistance (you can perform 75% of activity)3 Moderate assistance (you can perform 50% of activity)2 Maximal assistance (you can perform 25% of activity)1 Total assistance (you can perform 0% of activity)
Self-Care: Locomotion Walk & Wheelchair*

7 Complete independence (timely, safely)6 Modified independence (device)5 Supervision4 Minimal assistance (you can perform 75% of activity)3 Moderate assistance (you can perform 50% of activity)2 Maximal assistance (you can perform 25% of activity)1 Total assistance (you can perform 0% of activity)
Self-Care: Walk*

7 Complete independence (timely, safely)6 Modified independence (device)5 Supervision4 Minimal assistance (you can perform 75% of activity)3 Moderate assistance (you can perform 50% of activity)2 Maximal assistance (you can perform 25% of activity)1 Total assistance (you can perform 0% of activity)
Self-Care: Wheelchair*

7 Complete independence (timely, safely)6 Modified independence (device)5 Supervision4 Minimal assistance (you can perform 75% of activity)3 Moderate assistance (you can perform 50% of activity)2 Maximal assistance (you can perform 25% of activity)1 Total assistance (you can perform 0% of activity)
Self-Care: Stairs*

7 Complete independence (timely, safely)6 Modified independence (device)5 Supervision4 Minimal assistance (you can perform 75% of activity)3 Moderate assistance (you can perform 50% of activity)2 Maximal assistance (you can perform 25% of activity)1 Total assistance (you can perform 0% of activity)
New Dog Information
Describe your ideal dog.*
What three things do you think a dog could help you with?*
Example: retrieve items, wake from a nightmare, etc.
How are you going to exercise your dog and how often?*
What other activities do you plan to do with your dog?*
How many hours per day will your service dog be left alone (if any)? *
Where will the dog be when left alone?*
When you are home, where will the dog be?*
Are there any parts of the house where the dog will not be permitted?*
Where will the dog sleep during the night?*
Dog/Pet History
Have you had any dogs in the last five years?*

YesNo
How many dogs have you had in the last five years?*
If you no longer have one or more of the above-listed dogs, please explain why not:*
Please list all current dogs in your household. List breed, age, gender, and if spayed/neutered:*
Please list any other pets in your household.*
Birds, cats, etc.
Please list your veterinarian's name and contact information.
If you don't have a current veterinarian, do you have one in mind you would use?
Service dogs can run into difficulties and create problems for the team if the client does not use the dog appropriately and according to the law. To complete the application, please read and select the checkbox for the following statements.

(You're almost finished!)
Please select who has completed this application.*

MyselfA Parent or Duly Authorized Representative
I acknowledge that I have read and understood the Client Placement Overview & Policy, as well as the steps for the application process, listed at the beginning of this application.*

YesNo
I acknowledge that the information contained on this form is true and correct. I understand that any misrepresentation of facts may result in the removal of the dog from my home.*

YesNo
I have the capacity to bathe, toilet, groom, provide proper nutrition, exercise and ensure proper veterinary care for the dog*

YesNo
I have the capacity to meet the service dog's social and emotional needs throughout the dog's life*

YesNo
I have the ability, motivation, and acceptance of the responsibility for using the dog appropriately*

YesNo
I have the financial means to cover the annual cost (food, veterinarian care, flea treatment, supplies, other medicine as needed) for a dog for its life, including the potential for an increase in expenses after the dog retires (estimated to be $1000-$5000+/year)*

YesNo
I acknowledge and understand that after successful completion of the team training course, I will be required to follow up with New Life K9s for the remainder of my working partnership with my dog*

YesNo
I acknowledge submission of this application does not guarantee me to receive an assistance dog*

YesNo
Signature*

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By typing in your name below you are signing that the information on this application is correct to the best of your knowledge.*

First NameLast Name
Today's Date*

YearMonthDay
Date
The parent or duly authorized representative is required to sign below pursuant to state and federal law. *

First NameLast Name
Authorized Representative Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized Representative Phone Number*

Area CodePhone Number
Authorized Representative Relationship to Applicant*
Today's Date*

YearMonthDay
Date
How would you like to submit your one-page letter stating your reasons for wanting a service dog and how you feel the dog would benefit you?

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Upload your one-page letter stating your reasons for wanting a service dog and how you feel the dog would benefit you below.

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Please remember, you must also ensure the following 3 items for your application are completed by the appropriate people and sent directly to New Life K9s.
1. The Medical History form completed by your physician or primary care specialist (must download separately)
2. A personal letter of reference from a friend, teacher, or someone other than a family member
3. A professional letter of reference from a therapist, social worker, teacher, or any other professional with whom you have contact
Please send to PO Box 4412, San Luis Obispo, CA 93403 or by email to newlife@newlifek9s.org.
Applied For:

Service Dog
Status

Pending
Please verify that you are human*
Should be Empty:

Service Dog Application

Application Steps

Qualification Questions

General Information About You

Emergency Contact Information

Employment Information

Personal Information

Medical Information

Motor Impairments

Sensory Impairments

Cognitive Impairments

Communication Impairments

Psychological / Behavioral Descriptions

Additional Medical Conditions

Please identify Functional Independence Measure (FIM) levels for the following motor activities.

New Dog Information

Dog/Pet History

Service dogs can run into difficulties and create problems for the team if the client does not use the dog appropriately and according to the law. To complete the application, please read and select the checkbox for the following statements.