New Client Request Ready To Start Your Service Dog Journey? Before You Begin - Click Here To Check Out The Cost Fill out the below information to start today. The more detailed, the quicker we can assess your need.Name* First Last Email* Enter Email Confirm Email Phone*Address* Street Address Apt/Suite City Choose your StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Will the training occur at the above address?*Available trainers are assigned based on the address provided. Yes - I request a trainer based on the above address No - I request a trainer based on the below address provided Not Applicable - I wish to self train with guidance. You have chosen 'Self Training with Guidance'. Legally, in accordance with the Americans with Disabilities Act (ADA), an individual is allowed to train their own Service Dog. We can assist with self- training via coaching using videos, Skype, telephone, and/or email. This option is also offered to those in areas that we do not cover. For a listing of what areas we cover please click here.Address* Street Address Apt/Suite City Choose your StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Will the Service Dog be for you or a family member?* Myself Spouse Family member 13 years old or older Family member under the age of 13 Please select your age* Less than 13 13 - 17 18 - 24 25 - 29 30 - 39 40 - 49 50 - 59 60 and over Name of Spouse* Please select your spouse's age* 18 - 24 25 - 29 30 - 39 40 - 49 50 - 59 60 and over I prefer not to say Name of Family Member* Age of Family Member* Please choose your or the family member's condition(s) ADHD Addison's Disease Adrenal Failure Agoraphobia Alzheimer’s Disease Anxiety Asperger’s Autism Bipolar Cancer Cerebral Palsy Conversion Disorder Depression Diabetes Down Syndrome Dysgraphia Fibromyalgia Hearing Insomnia Medical Alert Military Sexual Trauma (MST) Mobility Multiple Sclerosis Muscular Dystrophy Night Terrors Obsessive Compulsive Disorder (OCD) Pain Management Panic Attacks Parkinson’s Disease Postural Orthostatic Tachycardia Syndrome (POTS) Psychiatric PTSD Reflex Sympathetic Dystrophy Schizophrenia Seizures TBI Tourette’s Syndrome OTHER (See additional comments) Please note that we do not train dogs to stop a child with autism from attempting to leave the house. This request puts the dog at risk and provides a false sense of security.Providing the height and weight will assist us in finding a dog that matches the client's mobility needs.Client's Height4 Feet, 11 Inches or Less5 Feet, 1 Inch5 Feet, 2 Inches5 Feet, 3 Inches5 Feet, 4 Inches5 Feet, 5 Inches5 Feet, 6 Inches5 Feet, 7 Inches5 Feet, 8 Inches5 Feet, 9 Inches5 Feet, 10 Inches5 Feet, 11 Inches6 Feet6 Feet, 1 Inch6 Feet, 2 Inches6 Feet, 3 Inches6 Feet, 4 Inches6 Feet, 5 Inches6 Feet, 6 Inches6 Feet, 7 Inches6 Feet, 8 Inches6 Feet, 9 Inches6 Feet, 10 Inches6 Feet, 11 InchesOver 7 FeetClient's WeightLess than 200 lbs201-225 lbs226 -250 lbs251 - 275 lbs276 - 300 lbs301 - 325 lbs326 - 350 lbsGreater than 351 lbsWhat tasks would you like a Service Dog to help with?*Please list any adoptive equipment (crutches, cane, wheelchair, lifts, etc.) being used if applicableNumber of children under the age of 13 currently in the home None 1 2 3 Number of cats currently in the home* None 1 2 3 Number of dogs currently in the home* None 1 2 3 Do you wish to have your own dog trained?* Yes No I am interested in one of the listed Available Assessed Dogs*All the listed dogs have been assessed for temperament and trainability. They all know various commands, but are NOT fully-trained Service Dogs. Service Dog training starts when they are paired with a client. In addition, please note the location of the dog as you will need to meet the dog to ensure it is a match. We do not transport dogs. Yes - I can travel to the listed dog's location No - I wish to locate another dog with assistance No - I have located another dog Name(s) of the Available Assessed Dog(s) I am interested in Lifestyle of the Handler*On scale from 1 to 5, please rate the daily level of activity with which the dog would be involved. Since your Service Dog will be with the handler most of the day, this is to gauge how much activity and exercise the Service Dog will be getting and match the handler with a dog that has a similar lifestyle. 1 - Primarily very low activity to include long periods of sitting, as in a desk job or low physical mobility. 2 - Activities of daily living only, such as shopping, cleaning, watering plants, taking out the trash, walking the dog, mowing the lawn and gardening. No moderate or vigorous activities. 3 - Daily exercise that is equal to walking for 30 minutes at 4mph. For example, 15-20 minutes of activity, such as aerobics or jogging on a daily basis. Spending a good part of the day on their feet. 4 - Daily exercise that is equal to walking for 1 hour and 45 minutes at 4mph or jogging for 50 minutes per day. Spending a good part of the day doing some physical activity. 5 - Daily exercise that is equal to walking for 4 hours and 15 minutes at 4mph or jogging for 2 hours minutes per day. Spending most of the day doing heavy physical activity. Your Dog's Name* Your Dog's Breed/Mix (your best guess)* Your Dog's Age (your best guess)*2 Months3 Months4 Months5 Months6 Months7-11 Months1 Year1.5 Years2 Years2.5 Years3 Years3.5 Years4 Years4.5 Years5 Years5.5 Years6 Years7 Years8 YearsOver 8 YearsPlease check all that apply to your dog* Age (at least 3 months to 6 years) Is above the age of 6 years and the dog is in good health Up to date on all vaccinations and on monthly heartworm/flea/tick/parasite medication Willing to be petted and touched on all parts of its body, including back legs and on the face without incident Makes good eye contact Housebroken (can be trained if necessary) Seems to be genuinely interested it's "person" and seeks attention Responds to praise and petting Treat-motivated for training (not necessary, but helpful) When walking, is more interested on its "person" than on other distractions (other people, dogs) Not easily frightened (a response to a loud noise is to be expected, but the dog should not show excessive fear) Is friendly, calm, and generally "laid back" around all ages of children and male and female adults Exhibits no excessive barking (can be trained) Shows absolutely NO signs of aggression toward other dogs or people Absolutely no history of aggression Dog is microchipped Dog is spayed/neutered Parent's Name*Since you indicate that you are 17 years old or younger we do request a parent's name First Last Parent's Email*Since you indicate that you are 17 years old or younger we do request a parent's email address Enter Email Confirm Email Additional CommentsHow did you hear about us? I have served/I am currently in the US Armed Forces* Yes - I am currently in the US Armed Forces Yes - I have served No Military Affiliation Army Air Force Coast Guard Marine Corps Navy Are you deployable? Yes No Not sure My spouse has served/is currently in the US Armed Forces* Yes - My spouse is currently in the US Armed Forces Yes - My spouse has served No Military Affiliation Army Air Force Coast Guard Marine Corps Navy Is your spouse deployable? Yes No Not sure Thank You For Your ServiceAfter clicking the below submit button, you will be taken to a confirmation page. If you were not directed to the confirmation page please try again, clear your cache (mobile device cache or computer cache) or try another browser.