Service Dogs, Inc. (SDI)Client Application

SDI keeps your entire application confidential.

All application materials will become the property of Service Dogs, Inc.

Completed Client Application Checklist:

$50Non-refundable Application Fee

Client Application Form*

Signed Background Check Authorization

Two Letters of Recommendation from non-family individuals

For Non-Active Military Only: A Copy of Your DD214 Form

Required signatures.

  • Sign both application and background check where shown.
  • Keep a copy for your records

Return this complete and signed package.

(Please note: Incomplete or unsigned packets cannot be processed.)

MAIL TO:
Service Dogs, Inc.
Attn: Applicant Coordinator
4925 Bell Springs Rd.
Dripping Springs TX 78620

*Attach additional sheets as needed for any answer.

CLIENT INFORMATION / Date(mm/dd/yy)
First Name / MI / Last
Address / City
County / ST / Zip
Cell Phone / E-mail
(Please note, SDI applicants must have an active cell, text and email account.
These are our primary means of communication with applicants and clients.)
Hm Phone / Wk Phone
Age (must be 25 or older) / Birth date (mm/dd/yy)
Marital Status / Sex / Weight
Nearest Relative/Caregiver
Name / Relationship
Address
City / State / Zip
Cell Phone / Work Phone
This application must be IN THE WORDS OF THE PERSON WHO WILL USE THE DOG.
If writing is difficult for you, provide the name and relationship of person transcribing your words below.
Name / Relationship
How did you learn about SDI?
Military Personnel Only:
Do you have a military affiliation?
What branch?
Are you active or retired?
For non-active military clients, please attach a copy of your DD214 to this application.


DISABILITY PROFILE AND ASSISTANCE NEEDS

Which type of dog are you applying for?

 Service Dog

A service dog is trained to perform a minimum of three custom tasks for a person with a disability. The dog is granted full public access. Clients must be 25 years of age or older and capable of handling the dog in public without assistance.

 Hearing Dog

A Hearing Dog is trained to alert a hearing impaired person to sounds by touching them, then leading them to the sound when cued. The dog is granted full public access. Clients must be 25 years of age or older and capable of handling the dog in public without assistance.

______

What is your disability?

Do you have any other medical conditions, including mental health diagnosis?

 Yes No If yes, please describe.

How long have you had your disability?

If your disability was caused by injury, what progress have you made post injury?

Are you in or have you completed rehabilitation? Yes  No

If yes, please describe, including frequency, duration and type of therapy:

Please indicate the devices that you use:

Wheelchair:  manual  power  both  3-wheel electric scooter

 Walker  Crutches  Other

Which do you use most often?
Do you drive? / Take bus? / Cab? / Other? (List)

Please describe any other assistive devices you use, such as wheelchair ramp, lifts, prosthesis, cane, TTY, etc.

STRENGTHS AND ABILITIES

Please rate your abilities using a 1 to 10 scale.

Mark any aids you use:

Rating / Ability
Hearing?  Hearing Aid  ASL  Lip Reading  Other (List)
Speech? ____ Easily understood ____ Tone variation ____ Volume
Do you use a word board?  Yes  No 
Other device speech/hearing device? (list)
Vision? Do you use corrective lens?  Yes  No
If yes, do you have 20/20 vision with correction?  Yes  No
If you need additional visual assistance (large font, note taker, etc.) please describe:
Learning Ability?  Need assistance (list/describe)

Is falling a concern for you?  Yes  No

If yes, how often do you fall? Describe how you fall (like a tree, etc.), what commonly causes you to fall, and how you recover.

Please rate with one number for each limb below.

No Use  Full Use
1 2 3 4 5 6 7 8 9 10 / Left Side Rating / Right Side Rating
Hand Strength
Dexterity
Arm Strength
Arm Reach/Extension
Upper-Body Strength
Leg Strength
Leg Control

How do you handle the following?

Routine medications By yourself  Assisted  Provided by others

Your finances, checkbookBy yourself  Assisted  Provided by others

Driving By yourself  Assisted Provided by others

Housecleaning By yourself  Assisted Provided by others

Meals  By yourself  Assisted Provided by others

GettingdressedBy yourself  Assisted  Provided by others

Shopping, groceries, etc. By yourself  Assisted Provided by others

Personal Care By yourself  Assisted Provided by others

Email/Cell Phone useBy yourself  Assisted  Provided by others

What personal attendants (including family members) do you use?

 Personal Care Aide  Cooking  Cleaning  Medical  Other ______

Describe how many attendants and how often? (Daily, weekly?)

What is the medical outlook for your condition in the next 3-5 years?

Please describe any other limitations – common challenges you experience, mobility, physical strength, endurance, reaction speed, balance, vision, speech difficulties, heat, cold or pain sensitivity, your ability to read and understand written material - anything that might help us understand your needs.

PERSONAL AND WORK ENVIRONMENT

What work, school, or rehabilitation program(s) have you completed or are you attending?

What is your current work or school schedule?

What are your plans for work or school?

How many times a week would your dog accompany you in public?

Please list typical locations where your dog would go with you:

If you participate in sports, clubs, social groups or other special activities where your dog would accompany you, please list them.

Where would your dog NOT accompany you?

List the names and ages of the people living in your home and/or taking care of you on a daily basis, including their ages and their relationship to you.

Name / Relationship / Age

Do any other members ofyour household have a physical or mental disability?

 Yes  No

If so, how are they disabled and what are their limitations?

Please describe your home and yard:

If you have a yard, is your yard fenced?  No Yes

If yes, how tall is the fence?
What material is your fence, i.e. wood, wire, etc?

If you do not have a fenced yard, please describe how and where you will toilet your dog and exercise your dog. It will need to toilet multiple times daily regardless of weather conditions and exercise 30-60 minutes daily.

What pets do you have now? Describe and list type, breed, size and age.

Please list your veterinarian’s name and phone number.

Have you ever given a pet away or placed a pet in a shelter?  Yes  No

If so, why and what happened to it?

Have you had a dog before? Describe what kind, your age at the time, any training you did, and what became of it.

LIVING WITH A HEARING OR SERVICE DOG

An SDI dog must be the only dog in the home. If you have another, dog, are you willing to rehome your dog?  Yes  No

If yes, please explain where and how you will rehome.

Having a cat may delay our ability to match you with a Service or Hearing Dog but is not prohibited. If you have a cat, are you willing to rehome your cat?  Yes  No

If yes, please explain where and how you will rehome.

On a daily basis, how will you handle walking, clean-up after toileting, feeding, medicating, exercising, and grooming your SDIdog?

How will you handle the care of your SDIdog if you are hospitalized?

Can you commit to attending the following meetings at our Training Center in Dripping Springs, Texas at your own travel and lodging expense?

  • Applicant Orientation Day (1 day, 9AM – 4PM) Yes  No
  • Matching - to meet dogs (one or more 2hour sessions)  Yes  No
  • Team Training Week (9AM – 4PM, Mon-Fri)  Yes  No

Please explain any No answer

Can you restrict your calendar/activities to accommodate an initial 30-day bonding period? This is an intense training, learning and relationship-building period key to success.

 Yes  No

Please explain any No answer

We estimate the cost of care for a service dog is approximately $2000 per year. Are you able to take on this cost?  Yes  No

Please explain.

A good basic estimate for the cost of an SDI dog at $2000 per year based on the cost of food, treats, toys, accessories,annualvet checkup, vaccinations, and a small stipend for unexpected veterinary occurrences. However, serious veterinary issues can arise.

You routinely play fetch to exercise your dog. It suddenly starts limping,so you stop¸ but later your dog continues to limp and cannot put any weight on one leg. Your vet diagnoses a torn ligament requiring surgery – a not uncommon injury in large dogs. The cost will be anywhere from $2,500-$3,000 for surgery and post-operative expenses. Please describe how you would proceed.

DO YOU AGREE TO THE FOLLOWING CONDITIONS REQUIRED
TO RECEIVE AND RETAIN AN SDI DOG?

  • That there is a reasonable expectation that your medical situation will allow you to use and benefit from your dog’s skills for 8 to 10 years.

Yes  NoPlease explain either answer.

  • That an SDI dog will spend most of it time with its partner at home AND at work, at school, and social events and that it will NOT be in a yard or kennel or home alone for long periods of time.  Yes  No, explain
  • That an SDI Dog is not a family pet – it has a specific function in the partner’s life and minimal interaction with others.  Yes  No, explain
  • That you and your dog are ambassadors for Service Dogs, Inc., as well as for the entire assistance dog industry, and you are required to maintain your dog’s appearance and manners, as well as your handling skills for the working life of the dog.

 Yes  No, explain

  • That you assume full responsibility for maintaining appropriate training and behavior, annually updating your public access certification with an SDI evaluator and understand that SDI may reclaim the dog if you do not do so.

 Yes  No, explain

  • That an SDI dog cannot be allowed off leash except in a secure area. Exercise and elimination must be done on leash or in a fenced yard or dog run.

 Yes  No, explain

  • That you must assume full responsibility as caretaker of your SDI dog, in charge of its safety, health and welfare and that failure to do so can result in SDI reclaiming the dog. These needs include:
  • Medical care – all care prescribed by your veterinarian and routine annual care as directed by SDI.  Yes  No, explain
  • Nutritional care – including use of a good quality dog food and maintaining your dog’s proper weight.  Yes  No, explain
  • Daily exercise and play  Yes  No, explain
  • Cleaning up-- when your dog toilets in public and repairing any damage caused by your dog.  Yes  No, explain
  • Repair of Damage -- repairing or paying for any damage caused by your dog to others property.  Yes  No, explain

Sign below if you agree to the conditions listed above. Attach additional sheets if needed to explain any answer.

Signature Required / Date

Background Check Authorization

In order for us to process your application, we need a completed background check. Please fill out the information below. We will run the background check for you and destroy the sheet containing your SSN. Please type or print clearly.

First Name / Middle / Last
Address
City / ST / Zip
County / Move in date
E-mail / Date of Birth
Social Security # / Gender
If you have had another address in the last 5 years, please list below:
Address
City / ST / Zip
County / Move in date

Have you ever been convicted of a crime? A conviction will not necessarily bar you from receiving a dog.  Yes  No If yes, please describe:

Please read and sign this form in the space provided below. Your written authorization is necessary for completion of the application process.

I hereby authorize Service Dogs, Inc. (SDI) to investigate my background for purposes of evaluating my application for a service dog. I understand that Service Dogs, Inc. will utilize an outside firm or firms to assist in checking such information, and I specifically authorize such an investigation through companies chosen by Service Dogs, Inc. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application will not be processed further.

Signature Required: / Date:

Letters of Recommendation

Please list the names and contact information of two people who will provide letters of recommendation for you. We will need a physical letter from each included with the application or sent separately to Service Dogs, Inc.

Your application will not be reviewed until these letters are received.

1) Personal (not a relative)

2) Professional (Co-worker, counselor, pastor, social worker, etc.)

Personal (non-relative)
First Name / Last Name
Address
City / ST / Zip
Cell Phone / E-mail
Professional (Co-worker, counselor, pastor, social worker, etc.)
First Name / Last Name
Address
City / ST / Zip
Cell Phone / E-mail

Please include the letters in this packet or send letters of recommendation to:

Service Dogs, Inc., Inc.

Attn: Applicant Coordinator

4925 Bell Springs Rd.

Dripping Springs TX 78620

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