Autism Assistance Dog Application

CRITTERSWORK SERVICE DOG PARTNERS 423-609-3301

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Applications
- Apprentice Trainer Application
- Autism Support Dog Application
Service Dog Pre-Application

PTSD Assistance Dog

PTSD Assistance Dogs

Completing the Application

Every item on our application is very important to our decision making process.

Therefore, you are required to enter something in all the lines or the application will keep returning to you for completion.

If an item does not pertain to you, simply insert N/A in the space.

Post-Traumatic Stress Disorder PTSD.
Post-traumatic stress disorder is a type of anxiety disorder. It can occur after you’ve seen or experienced a traumatic event that involved the threat of injury or death.

Causes and risk factors
PTSD can occur at any age. It can follow a natural disaster such as a flood or fire, or events such as:
- Assault
- Domestic abuse
- Prison stay
- Rape
- Terrorism
- War
For example, the terrorist attacks of September 11, 2001 may have caused PTSD in some people who were involved, in people who saw the disaster, and in people who lost relatives and friends.

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PTSD Assistance Dog Application

* Indicates required field

Date *

Name *

First

Last

Home Phone Number *

Work Phone Number *

Cell Phone Number *

Emergency Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

County *

Number of years at current addresss *

Personal Information

Age *

Date of Birth *

Height *

Weight *

Type of Disability *

Other Special Areas of Disabiity *

Physical Mobility (check all that apply)

Mobility Checklist *

Walk Normally Crutches (one or two) Walk Slowly but Steady Cane (one or two) Walk Unsteadily Use Walker Non-ambulatory Braces Wheelchair: Manual Wheelchair: Power Artificial Limb Explain Use of Lap Board (All or Part time)

Learning Disabilities

Do you have a Learning Disability? *

Yes No

If you are Learning Disabled, Describe in Specific Detail. *

Write as much of a description with as much detail as possible.

Vision

Are you Vision Impaired? *

Yes No

Describe your Vision Impairement *

Notice: We do not train Guide Dogs.

Hearing

Are you Hearing Impaired? *

If Hearing Impaired, Describe *

Speech

Are you Speech Impaired? *

Yes No

If Speech Impaired, Describe how you communicate *

If Yes, describe your Speech Impairment *

Hand and Arm Mobility

Which is your Dominant Hand *

Describe Hand or Arm Limitations in Detail *

Other Helpful Information

In order to match you to the best possibility of an Assistance Partner, we need to know as much about your physical, emotional, and learning limitations as possible. Please add anything that we have not covered in this questionnaire that we should know.

Other Limitations Not Covered *

Your Environment

Name / Sex / Age of person living in your home. *

Please select one, you live in a: *

Please indicate what type of home you live in.

If you sleected 'Other' please describe. *

Describe in detail your personal living arrangements.

Your Typical Day

Do you attend school? *

Yes No Part-time

If you answered yes or part-time, please tell us about the school *

Do you work? *

Yes No

If you work, what kind of work do you do? *

What hobbies or other activities are you involved in? *

Do you spend a majority of your awake time in bed? *

Yes No

What do you feel your level of activity is? *

Inactive Active 1-2 hours daily Moderately Active 3-6 hours daily Very Active 7-12 hours daily

Household pets

Dogs currently owned *

How many dogs live inside? *

Cats currently owned *

How many cats live inside? *

Who takes care of the dogs? *

Who trains the dogs? *

What is the name of your Veterinary Clinic? *

Veterinary Clinic Address *

Line 1

Line 2

City

State

Zip Code

Country

Veterinary Clinic Phone Number *

Have you ever been convicted of a felony? *

Yes No

Have you ever been convicted of an abuse charge? *

Yes No

Please tell us why you want a Service Dog.

Please tell us about yourself, your likes, interests, dislikes.

Tell us what activities you can't do in the course of a day that you feel a Service Dog could change for you.

Tell us about your past dog ownership.

I want a Service Dog because: *

Thank you for your submission, you will be contacted in two weeks.

I agree to receiving marketing and promotional materials *

Submit

CrittersWork Service Dog Partners, Inc.
357 Kitchen Branch Rd.
Greeneville, TN 37743-7266
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423-609-3301

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