Completed Facility Team Application Form

Thank you for your interest in a facility dog from Assistance Dogs of the West. Enclosed is the ADW Courthouse/Facility Dog Application packet and program information. Please return the completed packet to the P.O. Box 31027, Santa Fe, NM 87594. If you have any questions about the application, please feel free to call us at 505-986-9748 or email us at

A COMPLETE APPLICATION PROCESS WILL INCLUDE ALL OF THE FOLLOWING:
ADW will not accept incomplete applications. Please use this page as a checklist and keep copies of all forms for your records.

 Completed Facility Team Application Form

 Completed Facility Information Form

 Completed Fee Schedule Agreement

 A signed copy of ADW Privacy Practices

 A letter of agreement from the Head of your agency/facility

 A short autobiography

 Photographs: one of yourself, and some of your living environment, including indoor living spaces, your backyard, fencing (if applicable), and any pets living on the property; and the facility the dog will be working in.

 A letter of personal reference from a friend, co-worker, or someone other than a family member.

 Check, money order, or credit card payment for the $75 application fee.

Once we receive a completed application, you will set an appointment with ADW staff to help us understand the specific facility needs, environment and work style in order to match you with the right dog. All of this information is then used to conduct a staff review to determine whether applicants meet the profile for a successful placement candidate with an ADW facility dog.

When applicants are notified of acceptance into the ADW program, the final step is the waiting list. Client/dog interviews are conducted on a regular basis during this time to assess needs and potential matches. Out of state clients will coordinate interviews with ADW staff.

Once a match is made, the client is then scheduled Client Placement Training (CPT). The details of Client Placement Training will be discussed with the Executive Director. Please note that each facility placement is unique. A private, on-site training may be required.

Thank you for your interest in our program. Please do not hesitate to call with any specific questions you may have.

Sincerely,

Liz Napieralski

Administrative Director

Facility Team Application

This form is to be completed by the primary handler (the individual who will assume the responsibility of managing the facility dog's work and interactions, as well as managing the facility dog's health and well-being at all times).

PERSONAL INFORMATION

Full Name

Address Apt. Number

City State/ Zip Code

Date of birth Male Female

Home Phone Number

Cell Phone Number

Work/Alternate Phone Number

Facility Name

Do you have any physically disabling conditions or health concerns?

 Yes No

If yes, please describe:

EMPLOYMENT INFORMATION

Briefly describe your job at the facility or within the program:

Do you reside at the facility?  Yes  No

What days and hours do you work at the facility or organization?

Please describe your work environment at completely as possible, including physical layout, activity level, co-workers' activities, etc.

How many hours per day do you spend with facility or program clients?

Do you work with the facility clients or program participants in areas outside of the facility (e.g., going on outings, providing transportation or services in the clients’ home, etc.)?  Yes  No

If Yes, please describe:

What is your average length of association with facility clients or program participants?  Less than 2 months  2-6 months  7-12 months  1-3 years  3-5 years  5 or more years

How do you envision a facility dog being of assistance to you in your job and of benefit to your clients?

What do you envision as your responsibilities in utilizing a facility dog in your work?

How do you think having a facility dog working with you may change your work routine?

PERSONAL RESIDENCE INFORMATION

Do you live in: the city  the suburbs  a rural area  other (describe)

Do you live in a: House  condo  apartment  duplex  mobile home

 Residential facility or boarding house  other (describe)

Do you have an outdoor yard space that is accessible from your residence?

 Yes  No

If yes, is the yard : completely fenced  partially fenced  not fenced

If fenced, height of fence:

If no yard, please describe where do you plan to toilet and exercise a dog?

How many hours per day are you at home?

Do you plan to move in the near future?  Yes  No  don’t know

If yes, please explain:

HOUSEHOLD INFORMATION

Please list all members of your household (relatives, significant other, friends, roommates, etc.).

Name: ______Relationship: ______Age: ___

Does anyone in your household have a disability?  Yes  No

If yes, please describe:

How would you describe the activity level in your household?

 active  moderately active  quiet

Please list hobbies and recreational/social activities that you enjoy that may not fall into your typical schedule/routine:

What is your primary means of transportation?  own auto, drive self

 own auto, others drive van with lift public transportation

 other (describe)

Do you use public transportation (bus, rapid transit, ferry, etc.)?

 Frequently Occasionally Never

Is anyone in your household opposed or concerned about you getting an ADW dog?  Yes  No

If yes, please explain:

Are any pets currently living in your household?  Yes  No

Please list any pets (excluding dogs) currently living in your home:

Have you ever had a dog before?  Yes  No

Please list all the dogs currently in your home and/or that you have had in the past five years:

Breed Age Sex Spayed/Neutered What became of this dog?

(if not, why not?)

Please list behavior exhibited by one or more of the dogs in your home:

 alert barking at door knock protecting food or toys from people or dogs

 aggression other (describe)

Have you done any formal obedience training with your dog(s)?

 Yes No

Can you provide proof of vaccination for the dogs currently living with you?

 Yes No

ASSISTANCE DOG INTEREST INFORMATION

Are you willing to be matched with a dog regardless of breed, size, color or gender?  Yes  No

If No, please explain:

Do you have any expectations or requirements concerning the temperamental characteristics of an ADW dog?  Yes  No

(Even though all of the dogs are highly skilled and appropriate for their working roles, every dog has his/her own individual temperament and personality. Not all placeable dogs are appropriate for every situation.)

If Yes, please explain:

FACILITY INFORMATION

Facility or Organization Name:

Facility Director Name:

Facility Address:

City, State, Zip:

Facility Phone Number:

Type of facility or program:  clinic private practice community

 hospital acute care out patient in patient hospital

 school treatment center long term care facility

 child advocacy/CASA courthouse/DA domestic violence shelter

 other (please describe):

Facility/program statement of purpose:

How many individuals reside at or are served by the facility or program?

What is the age range of the facility/program clientele?Average age:

General description of population served by the facility/program:

(List specific diagnoses if applicable)

Average length of client residency or involvement:

What is the ratio of staff to clients?

What is the annual rate of staff attrition?

What measures have been taken to poll staff and clients to determine support for a facility dog placement?

What concerns have been expressed?

What favorable reactions have been expressed?

What is the overall reaction of the staff toward a facility dog placement?

Do you have a place at work to leave the facility dog for a short period of time for those times when you are not able to supervise his/her work or interactions (such as work with clients when a facility dog’s presence may not be appropriate)?  Yes  No

If Yes, please describe. If not, how will you manage such times?

Does the facility have yard space that will be appropriate for a dog to eliminate or exercise?  Yes  No

Is it fenced/enclosed?  Yes  NoHeight of fence?

If needed, is the facility prepared to build a special enclosure? Yes  No

What experience, if any, does your facility have with animals in practice?

Does your facility have a written policy regarding animals in the facility?

 Yes No (If Yes, please include this policy in your application materials)

Are there any questions or concerns you would like to discuss with ADW or other ADW facility team graduates?

Additional comments:

As the facilitator in a facility team placement, you will be responsible for the dog at all times, working hours and off work hours (evenings, weekends, holidays, etc.).

The facility dog will travel to and from work with you and reside with you when you are not at work.

You will be responsible for the dog’s work, maintaining his/her skills, as well as managing his/her health and well-being.

Do you understand that you and/or your facility will have the financial responsibility of caring for the assistance dog (providing food, veterinary and all aspects of health care, including professional grooming if you are unable to do this yourself)?

 Yes No

______

Handler SignatureDate

______

Facility/Program Director/Administrator SignatureDate

Client service fee schedule [A]

The Assistance Dogs of the West client/dog matching program is a

three-stage process. Payment is due at the beginning of each stage unless otherwise arranged.

I. Initial Assessments and EvaluationTotal $525

Application Fee: $75

Client Screening: Initial Interview by Assistance Dogs of the West

(up to 2 hours)$450

II. Upon Acceptance Total $1,500

Interview Process $1,500 up 15 visits

(If a match is not made within the initial interview process (15 visits); subsequent interviews will be charged at $75 per visit)

III. Client Placement Training Total $4,100

CP Starter Pack $350

Classes and Public Access Training$3,750

Out of State Placement FeeTotal $1,500

To accommodate additional administrative costs and trainers’ fees.

______

Client Services Total: $6,125 in-state;
$7,625 out-of-state

IV. ADW Private Client Placement Training

ADW provides a private-placement option for a fee of $10,000, which customizes Client Placement Training (CPT); the dog and handler(s) train and work together in your setting. A professional trainer(s) will instruct a primary and secondary handler. Should you require more staff to be trained, we will provide an additional trainer and dog to accommodate your needs for a fee of $1,000 per two additional handlers. Expenses are billed separately.

Standard CPT services are included, and enhanced in the following ways:

Professional training in the environment(s) where handlers will work the dog, which facilitates learning for the team

Immediate ability to troubleshoot any issues or questions that arise

Set up practice scenarios for handlers and staff to increase confidence and professionalism

Systematically build handling skills in real work environments

Train all staff on the protocols of having a Courthouse Dog in the office

Provide tasks that are specific to your offices, especially to reduce the trauma in children during high conflict visits

Gain fluency in actual courthouse settings or other facilities where the dog may be required

Provide ongoing support

PLEASE READ CAREFULLY AND SIGN AND RETURN A COPY OF THIS PAGE WITH YOUR APPLICATION:

I have read and understood the client service fee schedule:

______
NAME (Please print clearly) SIGNATURE

Date ______

YOUR RIGHT TO PRIVACY - HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper or orally are kept properly confidential. This Act applies to all health care providers, it is intended to standardize health care information as well as ensure privacy and security of patient information. As a result of this act, this business would like to advise you of how we will protect the privacy of your or your child’s medical record.

As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

If you sign a consent form, we may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations

Treatment means providing, coordinating or managing health care and related services by one or more health care providers. An example of this would be disclosure of your Protected Health Information (PHI) to providers outside this business such as your outside case manager, treatment team members, doctors, nurses and other health care providers in connection with your health care treatment.
Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities and utilization review. An example for this would be telling your health plan about treatment you are going to receive to determine whether your plan will pay for the treatment.
Health Care Operations includes the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis and customer services. For example, we may also disclose PHI to doctors, nurses, therapists, students and other health care personnel for teaching purposes.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

Legal Authority to make health care decisions for minors or others Usually, the health information rights described in this Notice may be given to a person with legal authority to make health care decisions for a child or other person (for example, a parent of legal guardian). There are exceptions. For example, in New Mexico some health care services can be provided to a minor without the consent of a parent, guardian or other person. In these cases, the minor has the rights described in this Notice for health information related to the health care service provided.

We may without prior consent use or disclose protected health information to carry out treatment, payment or health care operations in the following circumstances:

In emergency treatment situations, if we attempt to obtain such consent as soon as reasonably practicable after delivery of such treatment;
If we attempt to obtain your consent but are unable to do so due to substantial barrier so communicating with you and we determine that in our professional judgment, your consent to receive treatment is clearly inferred from circumstances.

We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest of you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to our Privacy Officer or your therapist.

The right to request restrictions on certain uses and disclosers of PHI including those related to disclosures to family members, close personal friends, or any other person identified by you. We are however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
The right to reasonable requests to receive confidential communication of PHI from us by alternative means or at alternative locations.
The right to inspect and copy your PHI.
The right to amend your PHI
The right to receive an accounting of disclosures of PHI.
The right to obtain a paper of this notice from us upon request.

PERMITTED USE OR DISCLOSURE WITH AN OPPORTUNITY FOR YOU TO AGREE OR OBJECT

Research as a professional medically based therapeutic center, we may use and disclose PHI about you for research purposes. We will only use and disclose your information for a research project if we obtain your permission or if the need to obtain your permission has been waived by a designated review committee that meets Federal requirements.
Promotional Communications this business does not share or sell your PHI to companies that market health care products or services directly to consumers. This business may maintain mailing lists of individuals for promotional materials and news about ADW or training ideas. These include our newsletter and other information of this nature. You may be included on these lists. This business may send information about its programs and services to the individuals on these lists. If you wish to be removed from the mailing lists please send writing notice to ADW at P.O. Box 31027, Santa Fe, NM 87594
To Avert a Serious Threat to Health or Safety we may use and disclose PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of others. Disclosure will only be to persons who could help prevent the threat.
To Have Supervised Students Providing Care this business’s prides itself for remaining on the cutting edge of providing teaching assistance. One of the ways we maintain this status is by arrangements with student trainers and their families across our program. We have students and volunteers observing or doing rotations with ADW that last from a few days to the entire school year. Student trainers and volunteers are supervised by our staff according to the requirements of professional standards. If you object to having a student trainer or a volunteer involved in your interviewing or placement, please send written notice to ADW at P.O. Box 31027, Santa Fe, NM 87594
To Have Your Picture Taken we have taken pictures of clients to use in the training process, in publications to demonstrates specific training approaches, for training other clients, family caregivers and ADW staff. We require written permission for photographing or videotaping a client or session prior to doing so. If you change your mind and decide that you no longer want our business to take images, we would like writing permission sent ADW at P.O. Box 31027, Santa Fe, NM 87594. However, any images that this business had taken prior to this decision remain property of our business and we shall continue to use them.

USE OR DISCLOSURE PERMITTED BY PUBLIC POLICY OR LAW WITHOUT YOUR AUTHORIZATION