Veterans Moving Forward, Inc.
Service Dog Application
Dear Veteran,
We are glad you found us. As you know, Veterans Moving Forward, Inc. (VMF) trains and provides service dogs to veterans with physical and/or mental health challenges, at no cost to the veteran. We pride ourselves on a high success rate in placing service dogs with veterans. Our success results, in part, from our comprehensive matching process that begins with this application. Please note that submitting an application does not guarantee receipt of a service dog from VMF.
VMF’s service dog application and approval process can take up to six months. To help the process move smoothly and quickly, ensure you submit a complete and signed application, including all required documentation and attachments (as listed at the top of the application). Upon receipt of your application, VMF will contact you and your health care team to ensure we have all the information necessary to process your application and address any questions you may have. Our application review process includes conversations via telephone, as well as on-site, in-person interviews at VMF’s Canine Training and Veteran Support Center in Dulles, Virginia. Please ensure you have a signed release on file with your health care team so they are able to participate in the requisite telephone conversations, confirm you are their patient, and can discuss your condition(s) with VMF’s Veteran Coordinator and professional medical practitioner team. You must also be able to travel from your home to VMF’s Center in Dulles on at least two, and potentially three, occasions.
Additional information about each step of the application process and sample interview questions are on our website ,at “What We Do” / “Veteran Information.”
We look forward to working with you, and determining how VMF may help you. Thank you for your service to our country.
Sincerely,
Mike Turner, LT. USN Ret
Veteran Coordinator
A completed application must include the following:
- The completed application form with signature.
- A copy of your DD 214 and other official document(s) from the VA verifying your Summary of Benefits or service-connected disability.
- A copy of your Veterans Administration (VA) letter Summary of Benefits documenting disability or comparable letter from a civilian institution.
Date: ______
Part 1 – Introduction of the Veteran
Applicant Name:______
Nickname (if applicable):______
Date of Birth: ______
Gender: Male Female
Branch of Service:______Pay Grade/Rank at Retirement:______
Marital Status: Single Married Separated Divorced
Describe your primary disability:______
______
If you have been diagnosed with post-traumatic stress disorder (PTSD), how acute are your symptoms, i.e., how often do you have flashbacks? How isolated are you? How angry do you get, and how often? How well do you sleep?
______
______
Are you in the VA system? Yes No
Part 2 – Contact Information
Address: ______
City:______County: ______State:______Zip:______
Temporary Address or Permanent Address
Preferred means of communication: ______Phone E-mail
Daytime phone number: ______work home cell
Evening phone number: ______work home cell
Other: ______work home cell
E-mail address (work): ______
E-mail address (home): ______
Emergency Contact Information
Name: ______Contact #______
Part 3 – Veteran’s Condition and Caregivers
Approximate weight:______Height:______
Are you able to walk without assistance? Yes No
If so, are you able to walk a distance of half a mile without resting? Yes No
If so, are you able to walk a distance of a mile without resting? Yes No
What weather conditions (temperature / snow) preclude you from going on a walk outside?
______
Please check all that apply:
Deafness Speech Impairment Reduced Stamina
Hearing Loss Coordination Problems Limited Mobility
Memory LossSlowed Development Spasticity
Vision Impairment Muscular Weakness
Other:______
Do you have any of the following?
Allergies Chronic pain Heightened emotions
Depression Skin sensitivity Balance issues
Brittle bones Sensitivity to heat/cold
Seizures. If yes, what type, how often, what treatments/medications are you (or have you) using to control the seizures?
Do you use any of the following?
Prosthesis Leg brace Electric wheelchair
Manual wheelchair Wrist brace Hearing aid
Crutch / cane Walker
Other: ______
Describe any other medical problems you have:______
______
______
How do these affect your daily living skills?______
Part 4 – How Could a Service Dog Help
What activities are you currently not performing that you believe a service animal would allow you to perform?
______
______
If you previously had a service animal that you no longer have, what activities did the service animal allow you to do which you currently cannot do?
______
______
If you currently have or previously had a pet, which activities does / did the pet allow you to do which you currently seek a service dog to enable?
______
______
If you currently have or previously had a pet that enabled you to do an activity you cannot do without the pet, why do you believe another pet wouldn’t allow you to perform the activity?
______
______
Part 5 – The Veteran’s Daily Life
What is the daily time commitment required for non-work/school (e.g., family and after work activities) responsibilities?
______
Veteran Employed or Attending School
What is your profession?______
What type of work do you do or are you studying?______
What days / hours do you work / go to school?______
What means of transportation do you use for commuting ?______
Would the service dog be going with you to work / school?______
Veteran Seeking Employment
What is your profession?______
What type of employment are you pursuing?______
Where do you hope to find employment (same / different city)?______
Would the service dog be going with you to your place of employment?______
What would the means of transportation or commuting be?______
Retired Veteran
What doyou do on a daily basis during your days / evenings (a typical day)?______
______
______
What are the days/hours you pursue your retirement activities?______
______
______
Is the service dog going to be with you during you typical daily activities?______
______
Part 6 Veteran’s Home Life
Please list all persons currently living with you:
Name / Relationship(family member, friend, colleague) / Gender M/F / Age / Home during the day / Allergic to Dogs
M F / Yes No / Yes No
M F / Yes No / Yes No
M F / Yes No / Yes No
M F / Yes No / Yes No
M F / Yes No / Yes No
M F / Yes No / Yes No
M F / Yes No / Yes No
Are all the individuals at the residence aware of your desire to get a service dog? Yes No
Where do you sleep?______
Where would the service dog sleep?______
What restrictions would be placed on the dog in your home?______
______
______
Are there other pets living at your residence? Yes No
What types of pets and ages?______
Where do these pets sleep?______
What restrictions are placed on these pets in your home?______
______
______
Part 6 Veteran and Service Dog Team
To develop into a successful Veteran / Service Dog team which will enable you to improve your quality of life, you must make a commitment to dedicated training periods and practicing skills necessary to send appropriate signals and develop the bond between you and the service dog.
Can you support two hours a day of training (may be non-continuous) every day to develop and maintain a team bond sufficient to pass annual service dog public access tests? Yes No
Can you support two hours a week of instructor led training (not counting commuting time to the trainer’s facility) for professional assistance with skill development? Yes No
It is important to remember a Service Dog is a dog so that to remain healthy and vigilant, they must get proper exercise and medical care.
Who will take the service dog on walks? ______
Please describe the neighborhood where the service dog can be walked?______
______
______
What weather conditions (temperature / snow) prelude going outside to exercise the service dog?
______
Are you able to throw a tennis ball for the dog? Yes No
Please describe the yard / neighborhood area where you can play with the dog. What fenced-in facilities are available?
______
______
Please describe the yard / neighborhood locations where you can take the dog to relieve itself when you are at home.
______
Please describe the yard / neighborhood locations where you can take the dog to relieve itself when you are at work / school.
______
What level of fiscal commitment can you make towards food / medicine / veterinary visits for the service dog?
Can you commit to $50 / month? Yes No
Can you commit to $100 / month? Yes No
Can you commit to $150 / month? Yes No
Part 7 Feedback
How did you hear about VMF’s program?______
______
Part 8 Required Documentation
Please enclose the following documents with your application:
- A copy of your DD 214 and other official document(s) from the VA verifying your Summary of Benefits or service-connected disability.
- A copy of your Veterans Administration (VA) Summary of Benefits letter documenting disability, or comparable letter from a civilian institution.
Part 9 – Declarations
Filing an application does not guarantee receipt of a service dog. Service dog placement is dependent on availability of service dogs in training that can fill the applicant’s needs as determined during the application review and veteran interview process.
I understand it is my responsibility to keep VMF informed of any changes in my address, phone number(s) and E-mail address, as well as changes in my interest in receiving a VMF service dog. I understand my application will be kept on file for two years.
Applicant Signature: ______Date: ______
Applicant Printed Name:______
Please sign and return the completed application to VETERANS MOVING FORWARD, INC.,
44225 Mercure Circle, Suite 130, Dulles, VA 20166,or scan and send via email as a PDF file attachment to .
Page 1VMF, Inc., ProprietaryJune 2017
Veterans Moving Forward, Inc. is a 501(c)(3) public charity that provides service dogs
to veterans with physical and/or mental health challenges.