Thank You for Your Interest in an Autism Assistance Dog (AAD)

Labs’ n Life Inc. Assistance Dogs

Dear Applicant,

Thank you for your interest in an Autism Assistance Dog (AAD).

Labs’ n Life Inc. will review your application to help you assess the possible benefits of an Autism Assistance Dog. It is our intention to place a dog best suited to each individual’s / family’s unique goals and lifestyle so it’s important to complete the attached questionnaire as clearly and honestly as you can.

An Autism Assistance Dog serves as a tool for the primary care provider. That individual will be trained as a handler for the Autism Assistance Dog. In most circumstances this handler will accompany the Autism Assistance Dog and recipient.

Family’s who have enjoyed successful placements of a Autism Assistance Dog have enjoyed wonderful benefits including greater access to daily activities of living, safety, companionship, and therapeutic achievements.

As you know there is a significant list of potential recipients. Please complete this application only if you feel that the benefit to your intended recipient will outweigh the care, financial commitment, time and on going training an Autism Assistance Dog requires.

Please note: It is your responsibility that Labs’ n Life Inc. receives all application materials requested on the following pages. Once your completed application is received we will contact you as soon as possible, usually within 3 weeks regarding our assessment of your suitability for this program. If any part of this application is not complete, the application will be sent back to you, this will delay the process.

If, after reviewing and assessing your application, you qualify to proceed further, you will be contacted and an in-home interview will be scheduled. After the in-home interview, trainers will meet and review all materials and make a decision on the suitability of an Assistant Dog in your home.

Once a suitable dog has been allocated, Labs ‘n Life requires a deposit of $1000 to cover the costs of initial assessments, interviews, etc. The full cost of a Labs ‘n Life Assistance Dog is $19,000. This includes weekly support at sessions for 6 months post placement in addition to ongoing 6 monthly assessments.

Any information that is found to be false may result in the termination of any further proceedings of this application. If you need further space for your answers, please use a separate piece of paper and be sure to enclose it with the completed application.

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APPLICATION

AUTISM SERVICES

Dear applicant: In order to expedite the application process, please ensure that you enclose the following with your application:

( )Complete Application Form including photograph of applicant (13 Pages)

( )Medical Reference from your family physician included with this application.

( )Personal Reference Letter from a friend, significant other or family member stating how

you would benefit from a service dog and kind of care they think you would provide for it.

( )If the dog is to attend school please return the attached School Awareness Form

included with this application.

( )Personal Information Consent Form

( )Map/Directions to you home.

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For office use only

Date Received: ______Items Missing:______

In-Home Interview Date & Time: ______Interviewed By: ______

Was Application Approved?( ) Yes ( ) NoTeam Training Date: ______

Follow-Up Date: ______Dog’s Name:______

Please note, all information provided will be kept private and confidential.

BACKGROUND INFORMATION:

Name of Applicant: ______Phone (H) ______

(To be completed by parent or guardian if under 18 years of age)

(M) ______

Address: ______Suburb: ______Post code: _____

E-mail Address: ______Date of Birth (Child): ______

Mother Name: ______Father Name: ______

What is the applicants’ full diagnosis?

( ) Autism( ) P.T.S.D.( ) P.D.D./N.O.S.( ) Aspergers( ) Rhetts

Additional Information:

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(1) How did you hear about Labs’ n Life Inc. Assistance Dogs ?

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(2)Current living arrangements: ( ) Parents

( ) Other: Please explain ______

(3)Number of children in family: ______Ages: _____

Name(s): ______

(4)Are there any other disabilities in your household? ______

If minor or under guardianship/ward of the court, parental or duty authorized are required to sign

Both Patents if applicable Printed Name: ______

Signature: ______

Relationship to Applicant: ______

APPLICANT HISTORY:

(5)Describe the applicants’:

Mobility: ______

Physical Strength: ______

Education/Grades: ______

Reaction Speed: ______

Balance: ______

Vision: ______

Speech: ( ) Verbal( ) Non-Verbal

Method of Communication: ______

Hearing: ______

Sound Sensitivity: ______

Light Sensitivity: ______

Touch Sensitivity: ______

(6)How does the applicant deal with anger or frustration?

______

______

______

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(7)Is the Applicant on any Prescribed Medications? Please list.

______

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(8)Does the applicant or member of the family have any allergies to animals?

( ) Yes ( ) No

If yes, do you have a plan to address this ______

______

(9)Describe applicants’ activity level:

( ) Low( ) Moderate( ) High

(10)Do both parents work outside the home?( ) Yes ( ) No

Please state place(s) of employment (parents): ______

Type of employment: ______

(11)What type of schooling does the applicant attend?

( ) Pre-School ( ) Regular Integrated classroom ( ) Specialized Program ( ) Home

Please state name of school: ______

Please state name of school Principal: ______

Is the school aware of this application? ______

Does the applicant have a 1:1 Education assistant while at school? ( ) Yes ( ) No

LIFESTYLE INFORMATION:

(12)Describe your house and garden: Own ____ Rent_____

______

______

______

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DOG INFORMATION:

(15)Does the child like dogs?

( ) Yes( ) No

Is there anyone in your family that does not like dogs?

( ) Yes( ) No

Does anyone living in this house have allergies to dogs?

( ) Yes( ) No

Does anyone is this house have a fear of dogs?

( ) Yes( ) No

Is there already a dog in the family? If yes, please give details.

( ) Yes( ) No

Is the entire family committed to the idea of having an Autism Assistance Dog?

( ) Yes( ) No

Do you consider yourself knowledgeable in dog care and behavior?

( ) Yes( ) No

Are you prepared to deal with both the time and expense of maintaining an Autism Assistance Dog? (Socializing, On-Going Training, Exercising, Grooming, Toileting,)

( ) Yes( ) No

Are you able to financially commit to maintaining an Autism Assistance Dog, which can cost over $1200.00 year for Vet care, food expenses and unforeseen circumstances?

( ) Yes( ) No

(16)Describe ways you believe an Assistance Dog can assist the applicant in Activity of Daily Living:

______

______

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(17)What tasks do you desire the Assistance Dog to perform? List in priority order:

______

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______

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(18)What type of equipment does the applicant routinely use that the Assistance Dog would have to become accustomed to?

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(19)Do you have a fenced garden? ( ) Yes ( ) No

If not, please explain how you will contain the dog in a safe environment:

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(20)A majority of the Team Training (When the family receives the dog and is shown how to utilize it) is done at location to be advised. You must be able to attend with out your children for a minimum of 5 days training. One or both parents/ guardian may attend but one must be in attendance at least 100% of the time. Can you commit to this?

( ) Yes( ) No

(21) Additional training is conducted at Labs ‘n Life sessions with young people present. You must have an appropriate Police clearance to enable you to work with students in the schools system. Do you have a current DSTI police clearance?

( )Yes( )No.

Thank you so much for your interest in Labs’ n Life Inc. Assistance Dogs. We will assess your fully completed application as soon as our office receives it., we will process your application as quickly as possible. All completed applications will be kept in a secure location and will only be reviewed by staff members of Labs’ n Life Inc. and will not be discussed outside our organization

We are a volunteer based organization and appreciate your patience as well as any help you can give.

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An initiative providing positive anticipation for youth

Labs’ n Life Inc.

Autism Assistance Dogs for children with autism

MEDICAL HISTORY FORM

(To be completed by the Physician, please print or type)

The following individual is applying for an Autism Assistance Dog from Labs’ n Life Inc. Labs’ n Life Inc. mission is to enrich the quality of life and enhance the independence of children and families living with autism and special needs through the use of specially trained Autism Assistance Dogs. Autism Assistance Dogs are trained to stop children from wandering into unsafe environments and have been shown to have a positive impact on a child’s communication, behaviour and social interactions.

Please fill out the form below and return to Labs’ n Life Inc. with the applicant’s completed application form. Any questions regarding this form should be directed to Labs’ n Life Inc. All information will be kept private and confidential.

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Date:______

Please release to Labs’ n Life Inc. any requested information regarding my condition. The information I will give will not be used for any other purpose than to evaluate and assess my situation in making a successful canine placement and assisting me with ancillary services. Labs’ n Life Inc. will keep this information confidential and will not share it with anyone but the professional staff of any agency that is involved in helping provide services to me.

Applicant’s Signature:______

Parent/Guardian Name:______Signature:______

(please print)

Relationship:______

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MEDICAL FORM

Patient’s Name:______Sex:______

Doctor’s Name: ______Phone#:______

Address:______

Date of last exam:______Patient Since:______

Patient Diagnosis: (attach additional sheet if necessary)

______

______

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Prognosis & effect of condition on individual’s ability to perform Activities of Daily Living (ADL): (ADL shall refer to the ability to meet personal care needs, i.e. feeding, toileting, dressing etc.)

______

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______

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Does this individual have any allergies? If so please list and describe symptoms.

______

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______
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Mental./Emotional Evaluation of Patient:

YESMinimally NO

A)Able to exercise judgment and

make decisions necessary for ADL ( ) ( ) ( )

B)Able to sustain attention span( ) ( ) ( )

C)Able to follow directions and learn( ) ( ) ( )

D)Able to control physical and motor

movement( ) ( ) ( )

E)Under medication which impairs

functioning( ) ( ) ( )

F)Capable of making decisions around

personal or other’s needs/safety( ) ( ) ( )

Is there any other medical information you feel Labs’ n Life Inc. should know when considering this application for an Autism Assistance Dog? Please list:

______

______

______

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Can you recommend this patient for an Autism Assistance Dog placement?

______

______

______

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Doctor’s Signature:______

Applicant’s Signature:______

(parent/guardian if applicant is a minor)

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An initiative providing positive anticipation for youth

Labs’ n Life Inc.

Autism Assistance Dogs

Personal Information Consent Form

As a registered charity we are required to comply with the Data Protection Act. The purpose of this act is to protect your right to privacy and to safeguard personal information that you give us.

This Act does not change the current practices and procedures that we have in place. The personal information collected by Labs’ n Life Inc. is essential to providing clients with services that meet their individual needs, volunteers with the training and information they need to be successful in their volunteer endeavors and to keep donors informed of Labs’ n Life Inc. activities.

Many of these procedures involve the disclosure or relay of information to our staff and volunteers. Although our procedures are unchanged we are required to obtain your consent regarding the collection, use or disclosure of your personal information. If you have any questions please do not hesitate to contact our office.

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I agree that all personal information that I provide to Labs’ n Life Inc. will be complete and accurate.

Full Name:______

Signature:______

Date:______

Name of Not for Profit Org:Labs’ n Life Inc.

ABN 655 839 40182

10 Gumnut Road

Seaford Rise,

SA 5169

Manager:Sue Dansie

SCHOOL AWARENESS FORM

(To be completed by the School Principal, please print or type)

The following individual is applying for a service dog from Labs’ n Life Inc. Labs’ n Life Inc. mission is to enrich the quality of life and enhance the independence of children and families living with autism and special needs through the use of specially trained Autism Assistance Dogs. Autism Assistance Dogs are trained to stop children from wandering into unsafe environments and have been shown to have a positive impact on a child’s communication, behaviour and social interactions.

Labs’ n Life Inc. understands that each school board will want to implement protocols and procedures related to Autism Assistance Dogs in the school system, if they do not currently exist. Should a service dog team seek placement in a classroom situation, Labs’ n Life Inc. is committed to working with schools and school boards to ensure a positive outcome for all involved.

Please fill out the form below and return to Labs’ n Life Inc. with the applicant’s completed application form. All information will be kept private and confidential.

School Name:______

School Address:______

Principal’s Name: ______Phone#:______

Applicant’s Name:______

Parent’s Name: ______Signature:______

I, the under signed, hereby acknowledge that I am aware that the applicant identified above is applying for an Autism Assistance Dog from Labs’ n Life Inc..

Principal’s Signature: ______Date: ______

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An initiative providing positive anticipation for youth