Pre-Qualification Intake/Application Form for the Psychiatric Service Dog Program
  • To submit your application every box must be filled in. If you are unsure of your answer put unsure or N/A.
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  • Your Contact Information
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  • Last Name:*
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  • First name:*
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  • Street Address:*
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  • City:*
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  • State:*Two letter abbreviation
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  • Zip or Postal Code*
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  • Home Phone:*
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  • Cell Phone:*
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  • Your email address*a valid email address
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  • Vital statistics
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  • Date of birth:*mm/dd/yyyy
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  • Gender:*
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  • Relationship Status:*
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  • Name of your spouse or partner:*
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  • Do you have children?*
    Yes
    No
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  • Emergency Contact
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  • Your emergency contact's full name:*
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  • Relationship to you:*
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  • Street Address:*
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  • City/State/Zip Code:*
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  • Phone number(s):*xxx-xxx-xxxx;
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  • Please answer yes that we may contact this person in case of emergency:*
    Yes
    No
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  • Mental Health Professional Contact Info
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  • Provide the name, address and contact information for the mental health professional over your care:
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  • Name*full name
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  • Address:*
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  • City/State/Zip Code:*
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  • Phone number(s):*
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  • Email*a valid email address
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  • Please answer yes that we may contact this person in case of emergency:*
    Yes
    No
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  • Health
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  • Describe your primary mental health issue(s):*
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  • Do you have persistent or frequent problems with any of the following?*Please check all that apply
    Anger
    Apathy
    Crying
    Disorientation
    Fearfulness
    Forgetfulness
    Insomnia/Difficulty Sleeping
    Moodiness
    Nervousness
    Nightmares
    Panic
    Restlessness
    Sadness
    Social Withdrawal
    Paranoia
    Other
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  • How long have you been participating in treatment/receiving medical care specific to your mental health issue?*
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  • What medications are you currently prescribed?*
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  • What symptoms do you experience due to your mental illness that you feel your psychiatric service dog can be trained to perform that will mitigate the effects of these symptoms?*Please describe the various ways you feel a service dog could benefit you.
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  • Have you discussed getting a Psychiatric Service Dog with your mental health professional?*
    Yes
    No
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  • Lifestyle
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  • Describe your home. Do you have adequate space to accommodate a dog?*
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  • Where do you live?*
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  • Your yard is:*check one
    Fenced
    Unfenced
    N/A
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  • Describe other members of your household. Do you have people in your life that are supportive?*
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  • Describe any animals (pets or livestock) that are part of your household:*
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  • How do you get around town? (i.e. van, own car, public transportation, friends) Are you able to do so yourself or can you depend on someone else to transport your psychiatric dog (PSDIT) to training sessions and the veterinarian as well as shopping for his/her food and other needs.*Please describe.
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  • Describe your home life, social activities, hobbies and lifestyle in general. What kind of activities are you involved (work, school, church)?*
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  • Do you travel regularly?*
    Yes
    No
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  • Describe a typical day in your life?*
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  • Do you have the financial resources to invest in a service dog? If, are you willing to advocate to obtain alternative funding support?*(i.e. family, friends, churches, spearheading fundraising, loans, foundations, etc)
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  • Are you financially capable of providing proper care for a dog long-term?*(i.e. food, vet care, etc.)
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  • Describe any prior training experience you have with dogs:*
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  • Do you have the time, patience, and willingness required to reinforce the training and skills that a dog will have acquired in our training program?*
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  • Have you ever partnered with a service dog?*
    Yes
    No
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  • Have you applied to other service dog programs?*
    Yes
    No
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  • You will need to commit that when your psychiatric service dog needs to retire that he/she remains as a family member in your home. Not all Psychiatric service dogs in training end up being able to fulfill their role as a fully trained psychiatric service dog. We need to know that you are committed to keeping the dog if this should be the case. Adopting a dog that we have temperament tested does not guarantee that he/she will end up being the right dog as your working psychiatric service dog, but we need to have your commitment to keeping the dog even if the dog “Washes out”.
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  • Are you willing to stay engaged for the life of the dog?*
    Yes
    No
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  • Click Submit to email this to us and we will review your application and get back to you as quickly as possible. Thanks so much for your interest in applying for a PSD through Healing Companions, Inc.
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  • Email*a valid email address
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