SERVICE DOGS FOR VETERANS
This application pertains specifically to those veterans seeking a dog to assist with PTSD and/or TBI. Because we also train dogs to perform other types of tasks, we invite you to share any additional needs you might have where a dog can be helpful.
Candidates for a Service Dog must have been in treatment for their PTSD a minimum of 8 months before placing an application for a dog and be a resident of California.
The questions we ask will help us to understand your needs and lifestyle so that we may be able to determine if we can help you with one of our dogs. Filling out this application does not guarantee that we will be able to place a dog with you. If your application is approved, but we do not yet have a dog in training to place with you, you will be placed on our waiting list. Waiting list times vary and we will be able to give you a better idea at the time you are approved for a dog.
Please print this application, fill it out by hand, and mail the completed application to:
The Sam Simon Foundation, 30765 Pacific Coast Highway, #113, Malibu, CA 90265
ALL INFORMATION YOU SHARE WILL BE KEPT CONFIDENTIAL
Name: ______Date: ______
Street Address: Mailing Address (if different):
______
______
______
Home Phone: ______Cell: ______Work: ______
Applicant’s Email Address: ______
Preferred method of communication? Phone ______Email ______
Emergency Contact (Name and phone number of a family member or close friend):
Name: ______Number: ______Relationship: ______
I live in a: House ______Apartment/Condo______Duplex ______
VA facility ______Mobile Home ______Rent a room ______
If you live in an apartment or condo, what floor do you live on? ______
Do you rent or own your own home? Rent ______Own ______
If you rent:
Name of Complex ______
Landlord’s name ______
Landlord’s phone number(s) ______
Landlord’s address ______
______
Describe the home environment and where the dog would live. (example: size, number of rooms, upstairs,
Downstairs, noisy, cluttered, etc.)
______
______
______
______
Do you have a yard? Yes ______No ______
Is your yard fenced? Yes ______No ______
If your yard is fenced, what are the dimensions? Length ______Width ______Height ______
Please describe the type of fencing. (example: chain link, wood, cement, and the size of all gaps).
______
______
______
LIFESTYLE
Date of birth: ______Age ______
Height ______Weight ______
Marital Status: Single ______Married ______Separated ______Widowed ______
Do you have children? Yes ______No ______Someday ______
If you have children, how many and what ages: ______
______
If you have children, are how comfortable are they around dogs? ______
______
______
______
MILITARY HISTORY
War in which you served:
Operation Iraqi Freedom ______Operation Enduring Freedom ______
Other ______
Branch of Armed Service: ______
Rank currently or at the time of discharge: ______
Current status of service: Active Duty ______Discharged ______Retired ______
Reserves ______Type of Discharge: ______
If you are not yet discharged from active duty, when do you expect this to occur?
______
______
WORK/SCHOOL
Do you work outside the home? Yes ______No ______
If yes, do you plan to take your dog to work with you? Yes ______No ______
If yes, please describe the environment at work and where your dog will be while you are working:
______
______
______
______
What does your supervisor say about you bringing your Service Dog to work? Are they supportive?
______
______
______
If you attend school, will you be taking your Service Dog to class with you? Yes ______No ______
If yes, what is your field of study and what is your class schedule?
______
______
______
______
______
If you do not plan to take your dog to work or school with you, where will your dog be while you are gone?
______
______
______
DOG EXPERIENCE
Have you ever had dog(s) before? Yes ______No ______
If yes, what kind(s) and when did you last own a dog(s)?
______
______
______
______
How long did you have each dog?
______
______
______
______
Describe some regular activities that you did with your previous dog(s)
______
______
______
______
______
Do you have any other pets? Yes ______No ______
If yes, what kind and how many and are they used to being around dogs?
______
______
______
______
Check all that apply:
Like ______Do Not Like ______to play with dogs.
Care ______Do Not Like ______when dogs lick me.
Like ______Do Not Like ______to take dogs for a walk.
Mind ______Do Not Mind ______a dog following me around the house all day.
Want ______Do Not Want ______my dog to have access to my entire house.
Mind ______Do Not Mind ______dog on the furniture
Comments for any of the above: ______
______
OTHER DOGS IN THE HOME
The Sam Simon Foundation Assistance Dogs Program reserves the right to deny placement of a Service Dog to any veteran applicant that currently lives with one or more other dogs. The Sam Simon Foundation, at their sole discretion, will make reasonable and educated assumptions on compatibility between dog(s) living with a veteran applicant and a Service Dog based on gender and temperaments of Service Dogs currently in training; as well as on the ability of a veteran living with other dog(s) to properly bond with a Service Dog.
Do you live with a dog(s) now? Yes ______No ______
If Yes, please provide the following information for each dog: Breed, Age, Primary Owner, Indoor/Outdoor.
______
______
______
What is your idea of a good exercise routine for a dog? How many minutes each day can/will you spend helping your dog exercise?
______
______
______
______
MEDICAL INFORMATION
When were you first diagnosed with PTSD? ______
Is your PTSD Service Connected? Yes ______No ______
Have you been hospitalized as an inpatient for PTSD? Yes ______No ______
If yes, how many times and when was your last hospital discharge for PTSD? ______
______
Are you currently in treatment for PTSD? Yes ______No ______
If yes, please describe the program:
______
______
______
How long have you been in treatment for PTSD? ______
______
Please list the names and locations of all mental health providers that currently prescribe medications and/or who meet with you to treat your PTSD:
______
______
______
______
Check all symptoms that you experience:
______Sound Sensitivity ______Rage
______Anxiety/Panic Attacks ______Nightmares
______Insomnia ______Hallucinations/Flashbacks
______Anger ______Other: ______
List all prescription and non-prescription drugs you currently take:
______
______
______
What side effects, if any, are you experiencing from the drugs listed above?
______
______
Do you consume alcohol on a daily basis? Yes ______No ______
If yes, what kinds and how much do you drink?
______
______
Have you ever been tested for seizures or Traumatic Brain Injury? Yes ______No ______
If yes, what were the results? ______
______
Check all medical conditions that apply to you:
______Arthritis ______Heart Disease
______Asthma ______Seizures or Fainting Spells
______Alcohol or Drug Dependency ______High Blood Pressure
______Allergies (list below) ______Hearing Loss
______Diabetes ______Vision Loss
______Dizziness/Loss of Balance ______Other: ______
List all allergies: ______
List any medical conditions not listed above: ______
______
MOBILITY:
______Yes ______No I get out of bed daily.
______Yes ______No I can get up and down from a chair.
Comments: ______
______
BALANCE:
______Yes ______No I have a problem with my balance.
______Yes ______No I am able to handle a large dog jumping on me.
______Yes ______No I am able to handle a large dog pulling on its leash.
Comments: ______
______
RESTRICTED USE OF ARMS OR HANDS:
______Yes ______No I have restricted use of my arms or hand.
Comments: ______
______
______Yes ______No I use a wheelchair.
Comments: ______
______
______Yes ______No I use other mobility aids.
List all and comments: ______
______
______
______Yes ______No I require the assistance of an aide or family member for daily living skills.
Comments: ______
______Yes ______No May we have permission to contact your physicians and/or health care providers
who are currently treating you? We would like to request information on your
medical condition to give us assistance in placing a dog with you.
If you checked “yes”, we will be mailing you Medical History Forms to give to all of your health care
Providers. One of these forms must go to your mental health provider (whom you currently see for
Therapy) to serve as your referral.
List all medical doctors/health care providers, and their specialties, that currently treat you:
______
______
______
______
FAMILY ASSISTANCE
For a Service Dog to be successfully placed with you, everyone living in your home must
like dogs and be happy living with a dog. They must be willing and able to support
your having a dog and assist with the care of your dog when you are unable to do so.
______Yes ______No I have talked with everyone I live with about getting a Service Dog. They
support my decision to apply for a Service Dog.
If no, comments: ______
______Yes ______No I have talked with everyone I live with about their willingness to support a
dog working for me. Everyone I live with (including caregivers) agrees they
will assist me with the care of my dog when I am unable to do so.
If no, comments: ______
______Yes ______No People living in my home like dogs.
If no, comments: ______
______Yes ______No People living in my home are afraid of dogs.
If yes, comments: ______
Who will take care of your dog if you are temporarily unable to do so?
______
List all other people living in your home:
NAME / AGE / RELATIONSHIPTO YOU / ANY PHYISCAL/
EMOTIONAL
CHALLENGES / WORK/SCHOOL
SCHEDULE
List all other people who visit your home frequently:
NAME / AGE / RELATIONSHIPTO YOU / ANY PHYISCAL/
EMOTIONAL
CHALLENGES / HOW OFTEN THEY VISIT
NEEDS & EXPECTATIONS
Describe a typical day for you (weekends and weekdays)
______
______
______
______
______
What are your concerns regarding adopting a Service Dog?
______
______
______
______Yes ______No I understand that Service Dogs are chosen for the people-friendly manners and
that they are not trained to be guard dogs?
______Yes ______No I understand that a Service Dog is certified to accompany me in in public
places such as restaurants, doctor’s offices, and stores. And is trained to
perform specific tasks only for me.
______Yes ______No I understand that a Service Dog cannot be helpful for me unless he/she is
with me most of the time.
Comments/Concerns: ______
______
______
______
FINANCIAL
Our trained Service Dogs are provided to you free of charge, but you are solely responsible for all costs of keeping your dog fed, healthy and working for you.
Normal, on-going costs for a Service Dog include, but are not limited to: dog food, toys and treats for training rewards, regular vet check-ups, and sometimes emergency vet treatments, and grooming. We estimate the yearly cost of having a dog to be approximately $1,000.00 annually. We do not recommend you apply for a Service Dog if it will be a financial hardship.
______Yes ______No I understand that I am fully responsible for the cost of care of the dog after
it comes to live with me.
______Yes ______No I expect to, and am able to, pay for all veterinary expenses.
______Yes ______No I understand that to keep a Service Dog working, I will need to buy pet
supplies such as toys and treats on an on-going basis.
______Yes ______No I understand that I need to feed my Service Dog a high quality dog food.
How will you pay for the needs of a Service Dog? (choose one) & (fill in the blanks):
______I can afford to pay whatever it costs to keep my dog healthy and working for me.
______I can afford to pay up to $______. If this is not enough, I have a family member willing to provide financial support. Name of family member: ______.
______I can only afford to pay up to $______. I do not have a family member able to
provide financial support.
In the event of an Extreme Veterinary Emergency Expense:
I will take care of the bill myself: Yes ______No ______
I will be able to get financial help from friends/family: Yes ______No ______
I will need special financial assistance: Yes ______No ______
My source of income is: ______
ABOUT YOURSELF
What is the best experience you can remember having with a dog?
______
______
______
______
______
What is the worst experience you can remember having with a dog?
______
______
______
______
______
How do you expect a Service Dog to help you?
______
______
______
______
List 5 words that you would use to describe yourself:______
______
ADDITIONAL INFORMATION
Have you ever applied for a Service Dog before? Yes ______No ______
If yes, from whom and what was the decision? ______
______
______
______
Have you ever received a Service Dog from another organization before? Yes ______No ______
If yes, when and from whom? ______
______
______
______
If you have had a Service Dog from another organization before, why are you applying for one from
The Sam Simon Foundation?
______
______
______
How did you hear about The Sam Simon Foundation?
______
Have you, or anyone living in your home, ever been convicted of a felony? Yes ______No ______
If yes, who, when, and what was the felony? ______
______
______
If the person filling out this application is someone other than the applicant, please provide name of whom and an explanation as to why this was necessary:
______
______
______
______
I hereby declare all information in this application to be truthful:
Signature: ______Date ______
You will need to print this application and fill it out by hand. Please answer all the questions. If they
do not apply, please enter N/A.
Send the completed application to:
The Sam Simon Foundation, 30765 Pacific Coast Highway, #113, Malibu, CA 90265
The Sam Simon Foundation considers all applicants and
does not discriminate for any legally protected status.