Paws’itive Teams
Voice:(858) 279-7297
Fax:(858) 279-7296
paws@pawsteams.org
San Diego, CA

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Pre Application for Service Dog Placement

If you feel you would qualify for a service dog and would like additional information, complete the following pre-application form.

This is not a formal application. It is an inquiry so we can learn more about potential applicants. We do not require formal applications until we feel we have an appropriate dog. Inquiries are kept in our files for future matching. Potential applicants are screened to determine individual needs and the ability to benefit from a service dog and to provide a safe and healthy living environment for the dog. Please Note: only those living in San Diego County will be considered. Please be assured that all information on this form shall be held confidential by Paws’itive Teams. None of the information will be released to any agency or person outside Paws’itive Teams without your express written consent.

Personal Information
Do you live in San Diego County? If no, do not proceed as our placements are limited to persons living in San Diego County.

Yes

First Name of Applicant:

Last Name of Applicant:

Street Address:

City and Zip:

Telephone:

Date of Birth of Applicant:

Occupation:

E-Mail Address:

Verify E-Mail Address:

Name of Person Completing Form (if Different from Applicant:)

Relationship to Applicant:

If person is a minor, please list name of parent or guardian:

Gender:
Male Female

Background Information
Please describe your disability and the nature of your physical limitations:

When were you first diagnosed?:

Do you use special equipment or assistive technology? (i.e. cane, wheelchair, van with lift, walker, braces, speech board, other devices). If yes, please give more information:

Have you ever experienced a stroke, head or brain injury? If yes, please give more information.

Do you have any cognitive impairments? If yes, please give more information.

Are there any life threatening aspects to your disability? If yes, please give more information.

If you had to go into the hospital or became very ill, who would take care of your dog?:

Who are the physicians taking care of your disability? ( Please give name, specialty, address, phone number):

Would you grant your doctor(s) permission to provide us with relevant health information?:

What prompted you to apply for a service dog now?:

Has a service dog been placed with you in the past? If yes, please give more information.

Can you describe how you believe a service dog will change your current lifestyle:?

Please describe the various ways you feel a service dog could benefit you?

Would you be able to meet the financial commitment required to maintain your dog’s ongoing needs after placement? (i.e. food, grooming, health care)

Do you feel you are capable of achieving and maintaining the leadership role in the relationship with a service dog? Describe any concerns you might have.

Do you have any learning difficulties that you are aware of? If yes, please give more information.

How do you learn best? (i.e. theory, visual, auditory, hands-on):

Residence/Lifestyle Information
Are you expecting a major change in your current way of life in the next year? (i.e. marriage, a baby, return to school, divorce, employment change, living alone, other). If yes, please give more information:
Describe other members in your home. Do you have an attendant?:

Describe prior and current experiences with dogs in your life. Do you currently have other animals living in your home?

Are you or other members living in your household allergic to animals? Please explain:

Select your home type:

Select your yard type:
Have you considered an area near your residence where you can relieve and exercise your dog on a regular basis? Please give more information:

Do you work or travel or go to school or volunteer? Describe your home life, social activities, hobbies and lifestyle in general.

How do you get around town? (i.e. van, own car, public transportation, friends) Please elaborate.:

How did you hear about Paws’itive Teams? Why did you specifically apply to Paws’itive Teams?:

Have you applied to another service dog program? If so, how long ago?:

Please be assured that all information on this form shall be held confidential by Paws’itive Teams. None of the information will be released to any agency or person outside Paws’itive Teams without your express written consent.

I certify that all statements I have made in this form are true to the best of my knowledge:

Please retype this code below :

After completing the entire form, click on the SUBMIT button below. You will receive confirmation via e-mail.

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