Service Dog Training Interest Questionnaire

Thank you for your interest in our service dog training program. This form helps us understand your needs, your lifestyle, and your dog’s suitability for service work. Please answer as thoroughly and honestly as possible. All responses are confidential.

Section 1: Applicant Information

Who is completing this form?

I am applying for myself

I am applying on behalf of someone else

Full Name of Applicant (person who will work with the service dog):

Date of Birth of Applicant:

Full Name of Person Completing the Form (if different):

Relationship to Applicant (parent, guardian, caregiver, etc.):

Contact Information (phone, email, address):

Preferred Method of Contact: (Phone / Email / Text)

Section 2: Disability & Support Needs

Please describe the applicant’s disability and how it affects daily life.

What specific tasks do you hope a service dog can assist with? (Examples: mobility support, medical alert, psychiatric support, task interruption, retrieving items, etc.)

Has a healthcare professional recommended or approved the use of a service dog?

Yes

No

Are there safety concerns we should be aware of (medical episodes, falls, elopement, etc.)?

Yes (please explain)

No

Please explain if yes.

Section 3: Communication & Independence (for children or non-verbal applicants)

Can the applicant communicate verbally?

Yes

No

Limited

Limited (please explain)

Does the applicant use alternative communication methods (sign language, device, gestures, etc.)?

Yes (please describe)

No

Yes (please explain)

How independent is the applicant in daily life?

Fully independent

Needs partial assistance

Fully dependent on caregiver

Does the applicant currently attend school, day programs, or work?

Yes (please describe)

No

Yes (please explain)

Are there specific behaviors or challenges (sensory sensitivities, social anxiety, wandering, self-harm, etc.) that a service dog would help with?

Section 4: Household & Environment

Who does the applicant live with (alone, parents, siblings, roommates, caregiver)?

Are there other children in the home?

Yes (ages)

No

Ages

Do you live in a house, apartment, or other?

Is there a fenced yard?

Yes

No

What is the daily routine like (school, work, therapy, home activities)?

Section 5: Dog Information

Do you currently have a dog you’d like to train as a service dog?

Yes

No

Dogs Name

Breed

Age

Sex (spayed/neutered)

Weight

Heath Issues

Vaccinations Current?

Has your dog received any prior training?

Yes (please describe)

No

Describe - on task, obedience details etc

How does your dog react to strangers, children, and other dogs?

Has your dog ever shown aggression, extreme fear, or reactivity?

Section 6: Training Goals & Expectations

Please specify if other:

What are the top 3 tasks you’d like the dog to perform?

Are you open to being matched with a different dog if your current dog is not suitable?

Yes

No

How committed are you to participating in ongoing training, public access work, and skill upkeep?

Very committed

Some what committed

Unsure

Section 7: Additional Information

Have you or the applicant worked with service dogs before?

Yes

No

Is there anything else we should know about the applicant, your family, or your dog?

Consent

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I certify that the information provided is accurate to the best of my knowledge. I understand that not all dogs are suitable for service work, and training requires a significant time and financial commitment.

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