Warriors Best Friend Foundation

Veterans with PTSD and TBI

Warriors’ Best Friend Foundation

Application for Service Dog

Application Process for Veterans with Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI)

1. Complete Part A: Personal Information (pages 3-11), AND Part B (Page 12): Background Check, of the application and submit by mail to:

Warriors’ Best Friend Foundation, P.O. Box 1432, Liberty, MO 64069

*** Please allow two weeks for review of this portion of the application. A representative will contact you to inform you if you have been chosen to continue in our selection process.

***If you have been contacted and asked to proceed, complete the following:

1. Complete Part CVideo (disc format)and mail to Warriors’ Best Friend Foundation.

1. Complete Part D-Letters of Recommendation. Letters of Recommendation must be mailed directly from the author to the P.O. Box address listed above.
2. Part E: Medical History (pages 15-21) is to be completed by the applicant’s Medical or Mental Health Provider. Warriors' Best Friend does not require the applicant’s full medical records. You may have the Provider’s office send the Medical History portion of the application directly to Warriors' Best Friend at the above contact address.
3. When all required items have been received, the application will be reviewed by Warriors' Best Friend (All parts of the application must be received before undergoing consideration). Warriors' Best Friend will contact the applicant to clarify any questions or concerns and answer any questions the applicant may have about the program.
4. If the application is tentatively approved, the applicant will be consulted by a representative of Warriors’ Best Friend to discuss the process of obtaining a WBF dog, including the time required to receive a WBF dog.
5. Questions regarding this process may be submitted

PART 1: PERSONAL INFORMATION

Warriors’ Best Friend will keep your entire application confidential. Your video and written application will become the property of Warriors Best Friend Foundation.

PERSONAL INFORMATION

How did you hear about Warriors’ Best Friend?______

______

First Name: ______Last Name:______MI:______

Birth Date: ______Gender:  M  F Weight: ______Height: ______

Martial Status: ______

Street Address: ______

City: ______State:______Zip:______

Home Phone: (______) ______-______Cell Phone: (______) ______-______

Email Address: ______

Branch of Service: ______Rank: ______

FAMILY

Nearest Relative: ______

Relationship: ______

Street Address: ______

City: ______State: ______Zip: ______

Home Phone: (______) ______-______Cell Phone: (_____) ______-______

History of Post-Traumatic Stress

Date of Disability (or first awareness of symptoms): ______

Was the injury sustained during active duty? ______

Please check all that apply:

 Having nightmares, vivid memories or flashbacks.

 Feeling emotionally cut off from others.

 Feeling numb or losing interest in things you used to care about.

 Becoming depressed.

 Thinking you are always in danger.

 Feeling anxious, jittery or irritated.

 Experiencing a sense of panic that something bad is going to happen.

 Having trouble staying focused on one thing.

 Having difficulty sleeping.

 Having a hard time relating to, or getting along with spouse, family or friends.

 Drinking alcohol or use of drugs.

 Pulling away from people and becoming isolated

For this next section, if you need more room to answer the following questions please list the corresponding question number and answer on a blank sheet of paper. Title the paper “History of PTSD.” Please staple to the back of your packet.

1. If any, what other symptoms related to PTSD affect you negatively?

______

2. Is the cause of disability combat related or other? Please explain below.

______

3. How specifically would you benefit from a Warriors’ Best Friend dog?

______4. Please describe your limitations—mobility, physical strength, endurance, reaction speed, balance, vision, speech difficulties, heat, your ability to read and understand written material, and anything that might help us understand your needs.

____________

5. Do you currently work? If so what do you do, and what is your basic schedule? ______

______

6. What are your future plans regarding work/ and or school? ______

______

7.Please describe your home and yard.______

______

8.Is your yard fenced?  No  Yes If yes, how high is your fence? ______

9. Do you share your home with anyone? List the people living in your home, including their ages and relationship to you.

______

10. What pets do you have now? Describe type and age.

______

11. Do you have an established veterinarian? If so, please list name and number.

______

12. Describe the types of dogs you have previously owned. ______13. Have you ever re-homed a pet? If so, what was the reason?

______

14. Do you have the time available in your schedule to walk, clean up after, feed, medicate, exercise, and groom your WBF dog on a daily basis?______

______

15. How will you handle the care of your WBF dog if you are hospitalized?

______

Expectations and Responsibilities of a Service Dog Owner

It is important to understand that a service dog is not a house pet, but rather a closest companion and a tool to be used to help alleviate (over time) symptoms related to post-traumatic stress disorder and traumatic brain injury. Because of this distinction there is a large difference in home care and financial responsibility of which you may not be aware. Please initial each statement signifying your agreement.

A Warriors’ Best Friend dog is to spend most of their time with their human partner.A service dog accompanies their partner on activities outside of the home whether that be work, school, and social events (in any place where a service dog has public access). These highly skilled dogs must be continuously worked with in order to maintain their level of skills, therefore—NOWBF dog will be in a yard or kennel for long periods of time. ______

A Warriors’ Best Friend service dog and their partner is a representation of Warriors’ Best Friend. It is required to keep up our service dog’s appearance and manners, as well as your handling skills. ______

Warriors’ Best Friend service dogs are well mannered and have been socialized with other dogs and people. However, when in public, a WBF dog must remain on a leash, ALWAYS. ______

As a service dog owner you are responsible for cleaning up after your dog’s waste in public places and for repairing any damage caused by your dog. ______

A Warriors’ Best Friend dog is expected to receive top care. In order to maximize their skills, endurance, and longevity they must receive prescribed and routine veterinary visits, receive proper nutritional care (through the use of prescribed diet), maintain their ideal weight, AND receive daily exercise and play. ______

The estimated cost of a service dog is approximately $2000 per year. This yearly expense includes the cost of food, a yearly checkup for your dog, vaccinations, and a small allowance for unexpected veterinary occurrences. ______

The following questions will help you to identify additional expenses you will incur as a service dog owner in order for you to determine whether you are ready to assume the financial responsibility.

Source of Income

 Employed  Self-Employed Government Benefits Other

If you are employed, please describe your work: ______

Number of years in current place of work: ______

Monthly Income: $______

Please estimate the following expenses on a Monthly basis where applicable:

Rent/Mortgage $______

Utilities$______

Medical Care $______

Car Payments $______

Credit Card Payments $______

Expenses for Animals in your home $______

Now, estimate based upon your monthly budget, how much you think you would be able to budget for the additional expenses of your service dog maintenance.

Dog food: $______(You can estimate that your dog will eat between 2-4 cups per day, depending on the size of the dog).

Treats: $______

Toys: $______

Grooming $______(this cost will vary dramatically based on the type of dog you get.

Savings towards veterinary expenses: $______

Is there a limit to the amount you could spend on veterinary care? If so, what is this amount? ______

Would you ever consider euthanasia due to medical costs? ______

______

Have you ever, in the past, had to euthanize a pet due to the cost of medical care? If yes, please describe the situation:

______

ACKNOWLEDGEMENT

Warriors’ Best Friend Foundation is a non-profit organization and relies on sponsorships and donations in order to place our service dogs free of charge. It takes many months to train a service dog at significant cost; consequently, Warriors’ Best Friend must have the best interest of the service dog in mind when placing that service dog with an applicant.

Therefore, Warriors’ Best Friend reserves the right to deny an applicant at any stage of the

process of acquiring a Warriors’ Best Friend service dog. We also reserve the right to remove a placed dog from a recipient if it is deemed necessary by staff.

Additionally, if the recipient should pass away within the first (1) year of the service dog’s placement, the service dog must be returned to Warriors’ Best Friend Foundation within thirty (30) days.While Warriors Best Friend does not anticipate any of the above-mentioned problems, we must inform all applicants of these possibilities.

Applicant Signature: ______Date: ______

Print Applicant Name: ______

Right of Ownership and Release Agreement

I Agree:

As per the terms of receiving a service dog at no cost to me, I agree to participate fully with the Warriors’ Best Friend program, which includes the collection of photography, video, and written copies.

Please indicate you acceptance by initialing here: _____

Right of Material Ownership (Copyright):

Unless otherwise specified, it is understood that any and all rights including editing, printing, duplication, distribution and all other copyright ownership entitlements and privileges regarding any collected photography, video, written copy, or any other media related materials collected by Warriors’ Best Friend Foundation or its affiliated parties in connection with the Warriors’ Best Friend program, shall remain the property and authority of Warrior’s Best FriendFoundation.

Please indicate your acceptance by initializing here: ______

Right to Release:

I hereby grant Warriors’ Best Friend Foundation the right to use and reuse, said photography, video, and written copy, in whole or in part, modified or altered, either by themselves or in conjunction with other materials, in any medium or form of distribution, and for any purpose whatsoever, including, without limitation, all promotional and advertising uses, and other trade purposes, as well as using my first name in connection therewith.

I hereby release and discharge Warriors’ Best Friend Foundation from any and all claims, actions and demands arising out of or in connection with the use of said photography, video, or written copy, including, without limitation, any and all claims for invasion of privacy and libel. This release shall inure to the benefit of the assigns, licensees and legal representatives of Warriors’ Best Friend Foundation.

I acknowledge acceptance of this agreement in full by affixing my signature hereto:

Print Name: ______

Sign Name: ______

Date: ______/______/ ______

Application Part B—Background Check

Fill out the information below (please print clearly). We will run the background check on your behalf, careful to destroy this sheet with your social security number.

First Name: ______Middle Name: ______Last Name:______

Gender: ______

Email: ______

Social Security Number: _ _ _-_ _ - _ _ _ _

Date of Birth: ______

Current Address:

Country: ______Street Address:______

City: ______State: ______Zip Code:______

Date Moved In: ______

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:

______

Application Part C-VIDEO

Video Outline

Please provide a 10-15 minute video in DVD format. Include the following information and label the video with your full name. If video equipment is unavailable to you, you may submit photos that address ALL of the items listed below.

Your video is critical. WBF reviews it frequently during the placement process to help select a service dog to best match your specific needs and lifestyle. Below is the criteria needed in the video in a checklist format.

☐ Share some information about yourself—interests, hobbies

☐ Describe your daily routine – work, school, and other activities

☐ Demonstrate how you move around inside your home and workplace or school

☐ Show us how you use your adaptive equipment

☐ Tell us how do you think a dog will be able to help you

☐ What are your expectations of an assistance dog

☐ Home – Video the interior and exterior of your home, your yard, (including any fencing), and your neighborhood (where you might walk with your dog)

☐ Show your interaction with any present pets you may have and demonstrate their personality to the best of your ability

Application Part D-Letters of Recommendation

Please list the name and contact information of two people who will provide letters of recommendations for you. We will need a physical letter from both people, either included with the application or sent separately to Warriors’ Best Friend Foundation.

1)Personal (not a relative)

2.) Professional (therapist, doctor)

Please send letters of recommendations to:

Warriors’ Best Friend Foundation

P.O. Box 1432

Liberty, MO 64069

1______

2.______

Application Part E- Medical History Form

HIPAA Authorization for Release of Information From

Applicant Authorization for Use and Disclosure of Protected Health Information

By signing, I authorize Warriors' Best Friend Foundationto use and/or disclose certain protected health information (PHI) about me to any business associate Warriors' Best Friend Foundation deems necessary beginning with the application process, including service dog training, and placement, and ending with termination of the relationship with Warriors' Best Friend Foundation.

This authorization permits Warriors' Best Friend Foundation to use and/or disclose the following individually identifiable health (Please check one):

Limited release of information (only as described below):

______

______

______

Any and all personal health information relevant to relationship between applicant and Warriors' Best Friend Foundation.

 I have elected to opt out of the release of my personal health information.

The information listed above may be used or disclosed for, but not limited to, the following purpose(s), unless applicant has elected to opt out of releasing personal health information:

Media publications, marketing promotions, determination of eligibility, customized training, service dog placement, grant writing, and fundraising purposes.

The purpose(s) is/are provided so that I can make an informed decision whether to allow release of the information. This authorization will expire on: ______/______/______.

I do not have to sign this authorization in order to receive consideration from Warriors' Best Friend Foundation. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the founder at: Joe Jeffers/Founder, Warriors’ Best Friend Foundation, P.O. Box 1432, Liberty, MO 64069

 I acknowledge receipt and understanding of this HIPAA Authorization for Release of Information Form.

Signed by: ______

Signature of Applicant or Legal Guardian Relationship to Applicant

______

Print Applicant's Name Date

______

Print Name of Applicant or Legal Guardian. (If possible,Applicant/guardian

must be provided with a signed copy of this authorization form.

MEDICAL HISTORY

Please ask your physician or therapist to complete this form. Sign the release below and ask your physician to return it directly to Warriors’ Best Friend Foundation.

Patient’s First Name______Last______Sex____Date of Birth______

Release of Medical Information

This authorizes you to release information regarding my condition to Warriors’

Best Friend Foundation. This information will be used to evaluate and assess my situation, and is essential for Warriors’ Best Friend Foundation to train a service dog to increase my independence. All information is confidential.

Parental or duly authorized consent is required, pursuant to state and federal law, if client is a minor, or under guardianship or conservatorship/ ward of the court.

Printed name______Date______

Signature______

Relationship or title and agency

______

Agency Address and Phone Number

______

To the physician or Therapist:

• We maintain confidentiality of our clients’ records. What you write here will not be shared with your patient unless you give the express permission.
• If you have any questions, please contact Warriors’ Best Friend at (816) 429-6305. Please mail the complete form to:

Warriors’ Best Friend Foundation

P.O. Box 1432

Liberty, MO 64069

Or fax to WBF: 866-442-8115

MEDICAL OR MENTAL HEALTH PROVIDER CONTACT INFORMATION

Provider Name: ______Specialty: ______

Street Address: ______

City: ______State: ______Zip: ______

Phone: (______)______-______Fax: (______) ______-______

PATIENT STATUS

Define Primary Disability:

______

Cause of Disability:

______

Are there significant secondary disabilities? ______If yes, please describe:

______

At what age was the patient disabled? ______Is the disability progressive? Yes No

EFFECTS OF VETERAN'S DISABILITY (PLEASE CHECK ALL THAT APPLY)

 Muscular Weakness

 Vision Impairment

 Memory Loss

 Deafness

 Coordination Problems

 Hearing

 Speech Impairment

 Limited Mobility

 Speech Impairment

 Delayed Development

 Reduced Stamina

 Spasticity

Other: ______

PATIENT SIDE EFFECTS (PLEASE CHECK ALL THAT APPLY)

 Heat/Cold Sensitivities

 Balance

 Depression

 Allergies

 Anger

 Heightened Emotions

 Brittle Bones

 Chronic Pain

 Seizures

EQUIPMENT REQUIRED (PLEASE CHECK ALL THAT APPLY)

 Wheelchair

 Manual:

 Power:

 Both:

 Hearing Aid:

 Crutches:

 Cane:

 Walker: