Name

Referred By

Phone

Address

Marital Status

Gender Identification

Who lives in your house?

Do you have support in obtaining a service dog from all members of your home?

Do you have other pets in the home?

Do you have a fenced backyard?

Are you a first Responder?

Service

Have you previously owned dogs?

Have you had a service dog previously?

Did you obtain professional training?

Emergency Plan for dog care if you are not capable of caring for the dog yourself?

Give an example of how you resolve conflict within your general life:

Select all that apply to the level of your comfort.

Do you have a diagnosis from a qualified professional?

Do you have support from your professional to obtain a service dog?

Do you have mobility issues?

Which tasks do you believe the dog will help you with?

Do you have transportation to weekly class within the St. Thomas area?

Will you agree to follow the rules and guidelines as set out by The Phoenix Canine Initiative (Quest Canine Services Inc)?

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

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