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Service Dog Application
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Contact Telephone
*
City | State
*
Email Address
*
Who is the Service Dog for?
*
Me
My Parent(s)
Psychologist or Social Worker
My Child or Grandchild
A Client
Other
Did a Doctor or Therapist recommend a Service Dog?
*
YES
NO
I am a Doctor, Therapist or Social Worker
Medical/Psychiatric Diagnosis (Check all that apply)
*
PTSD
Autism
Mobility Related
Anxiety
Brain Injury
I Lose Consciousness
Depression
Hearing Loss
Personality Disorder
Cognitive/Memory Issues
Vision Impairment
Other
HOW MUCH DISTRESS does your disability cause you? (Check all that apply)
*
Not sure if I can go on living
I function, but I am miserable a lot
Barely holding on
I wish I was dead a lot
I have terrible anxiety
I have terrible nightmares
I cry often
I wish I could cry
I am paranoid
I experience flashbacks
I am afraid I will lose it
I have been hospitalized for my disorder
I rarely leave my house anymore
My disability greatly affects my loved ones
N/A
What is Your EMPLOYMENT STATUS? (Check all that apply)
*
I am retired
I work at a job
I am self-employed
I am unemployed
I attend High School or College
I had to leave my job or school because of my disability
I am very sick physically and/or mentally, and can no longer can work
Psychological Outlook (Check all that apply)
*
I am a HAPPY PERSON
I am an UNHAPPY PERSON
I experience JOY and HAPPINESS in spite of my misery
I feel nothing anymore
How well do you want your service dog trained?
*
I want a real service dog trained to care for me
Trained like most pets
Doesn't listen off-leash
No better than most people's pet dog
When do you need a Service Dog?
*
NOW, I am desperately in need of a service dog
June 2020
December 2020
June 2021
December 2012
What is your PLAN TO PAY for your service dog? [Superdog is a FAMILY BUSINESS, not a 501c charity or an agency with low-income assistance]
*
I have money
My family will pay for a service dog
I have money for a Down Payment
How much money have you set aside for A DOWN PAYMENT?
Additional Information you would like to provide.
Message
Submit