Social/Therapy and Facility Dog Application

 

  1. Facility/Business/Individual Name:_____________________________________

 

2.   Mailing Address:____________________________________________________

_____________________________________________________________________

 

  1. Facility/Business President/CEO:_______________________________________

 

4.   Day Phone: (     )______________      Eve Phone: (     )________________

 

5.   FAX: (     )___________________     Email:________________________

 

  1. Social/therapy population dog is intended to help:

(   )Retirement homes                (   )Troubled youth                    (   )Hospice

(   )Alzheimer’s programs          (   )Learning disabilities (   )Hospital

(   )Seniors centers                    (   )Emotional disabilities           (   )Rehab center

(   )Children’s center                 (   )Counseling                          (   )Physical/

                                                                                                Occupational therapy

 

  1. Patient Behavioral or medical conditions that may impact selection of dog:

(   )Aggression              (   )Physical Limitations (   )Developmental Delay

(   )ADD or ADHD      (   )Reading Difficulties  (   )Brain Injury

(   )Depression              (   )Fear of Dogs                       (   )Other:______________