Basic Service Dog Request

Who Is Completing This Form?

I AM

Client Contact Information

A Client is the recipient of the services provided by the Canine Companions service dog.

PLEASE NOTE:
Canine Companions requires all people applying for a service dog to be at least 18 years of age; those applying for a service dog with a facilitator must be at least 5 years of age.

First Name

Last Name

Client Date of Birth

Enter the date using ONLY this format: mm/dd/yyyy

Middle Name/Initial

Prefix

Suffix

Nickname

Personal Email

Confirm Email

Please confirm your email

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Preferred Phone

Phone Type

Preferred Phone Method

Street Address

City

County

State

Mailing Zip/Postal Code

Contact Information - Completing for Client

Relationship to the Client

Full Name

Preferred Phone

Personal Email

Confirm Email

What type of service dog are you interested in?

Hearing Dog (for adults who are deaf or hard-of-hearing)Service Dog for Veterans with Service-Connected PTSD (for veterans of the US Armed Forces)Service Dog (for adults with physical disabilities)Service Dog with Facilitator (service dog for an adult or child who will work under the guidance of an adult facilitator)Facility Dog (for professionals)

Please view the introductory Hearing Dog video below:

Please view the introductory PTSD Dog video below:

Please view the introductory Service Dog video below:

Please view the introductory Service Dog with Facilitator video below:

Please view the introductory Facility Dog video below:

I acknowledge that I have viewed the above video *

After watching the video, what specific skills or tasks do you feel would be the greatest benefit in having a service dog for you or your loved one?

Some of the tasks Canine Companions' dogs are trained to do:

Retrieve and deliver dropped items.
Tug open a door or drawer.
Tug a laundry basket or help remove a sock or jacket.
Push with their nose to shut a drawer or open a door with an automatic push plate.
Pull a lightweight manual wheelchair over a short distance. (Adult service handlers only.)
Turn lights on and off.
Our hearing dogs alert those who are d(D)eaf or hard of hearing to various sounds in their environment.
Our service dogs for veterans with PTSD are trained in nightmare and anxiety interruption, among other skills.

I understand Canine Companions DOES NOT train or place dogs for the following:

Guide work for the blind.
Medical alert/response, including but not limited to seizures, diabetes, heart rate.
Balance support while walking.
Managing specific behaviors such as stimming, eloping, etc.
Provide supervision, navigation, or safety from environmental hazards, aggression or personal protection.
Solely for emotional comfort or social support, such as anxiety and/or depression. At this time, Canine Companions does not make placements with civilians diagnosed with PTSD.