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Service Dog Application
SERVICE DOG APPLICATION
Please enable JavaScript in your browser to complete this form.
YOUR NAME:
*
First
Last
1. FULLY-TRAINED MEDICAL & PSYCHIATRIC SERVICE DOGS.
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ADA Golden Retrievers, $32,000, $36,000 or $40,000
2. HOW WILL YOU PAY? Medical insurance and the VA do not buy service dogs.
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I was just planning on paying you
I can make payments (Balance due before dog goes home)
3. ARE YOUR PARENTS or SOMEBODY ELSE helping you pay?
No
PART or ALL OF THE COST is being paid by somebody else
4. Did the applicant's DOCTOR or THERAPIST RECOMMEND a service dog?
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Yes - Not required for ADA dogs
No
5. AGE when mental health issues first began or diagnosed?
6. MEDICAL DIAGNOSIS (Click all that apply). If the applicant is TOO SICK, too depressed, too anxious, too unpredictable, unstable, or detached from reality, etcetera, getting a service dog would not be in their best interest.
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PTSD
Traumatic Brain Injury
Depression
Medical Disability
Anxiety Disorder
Borderline Personality Disorder (BPD)
Autism
Other (Specify in the comments section below)
7. REASONS TO GET A MEDICAL SERVICE DOG. (Click all that apply)
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I have severe, disabling depression
I am terrified to leave home
I have severe, disabling anxiety
So I don't have to be alone
I have horrible, disabling PTSD
To make life easier for me
Distract me from horrific chronic pain
Help with racing or recurring thoughts
Stop my suicidal ideation
Interrupt nightmares or inappropriate behaviors
An alternative to a lifetime of drug use
I need meaning in my life
Reduce or eliminate psych meds
So I have a good reason to stay alive
APPLICANT - PERSON FILLING OUT FORM (Must be at least 18 years old)
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First
Last
NAME OF CHILD OR SPOUSE who needs a service dog:
APPLICANT'S AGE (Age of the person who needs a service dog)
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City
*
State
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Email
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Telephone
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8. Your Story. Who are you, what do you do, what happened, etc?
*
9. MORE INFORMATION about YOURSELF you would like considered. (Optional)
10. THE PERSON filling out this form and PRESSING THE SUBMIT BUTTON:
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I'm an ADULT OVER 18, applying for myself
I'm an ADULT OVER 21, applying for my child, spouse or parent
I am younger than 18 years old
STOP!!! DO NOT SUBMIT THIS APPLICATION YOURSELF KIDS. Your parents, conservator, attorney or legal guardian must submit the application for you from THEIR EMAIL ADDRESS. We cannot talk to you if you are UNDER 18 YEARS OLD. If you LIE ABOUT YOUR AGE or IMPERSONATE YOUR PARENT you will be banned for life and never be eligible to get a service dog ever again. YOU CAN'T FOOL US. WE WILL KNOW IF YOU LIE ON THIS APPLICATION!!!
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FOR FASTER SERVICE, call or text us at (916)701-6458 AFTER YOU PRESS SUBMIT. We ask that you submit this application first before calling us to save time, and so we can know how to best help you. All information is held in the strictest confidence and never shared with anyone.
Submit Application