Assistance Dog Assessment Form
Please complete this assessment so we can understand your needs, living situation, and preferences for assistance dog matching or support.
Applicant Information
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City/Town
Preferred Contact Method
*
Email
Phone
Text
Assessment of Need and Daily Function
How much does this task affect your daily functioning?
*
Minimal impact
1
2
3
4
5
6
7
8
9
Major impact
10
1 is Minimal impact, 10 is Major impact
How often do you need support with daily tasks?
*
Rarely
Sometimes
Often
Always
Functional support needs by task
*
Rows
Need level
Notes
Mobility support
1
Alerting
2
Retrieval
3
Grounding
4
Companionship
5
Which types of assistance could a dog help with?
*
Mobility support
Alerting
Retrieval
Grounding
Companionship
Other
How much could an assistance dog improve your independence?
*
No improvement
1
2
3
4
5
6
7
8
9
Significant improvement
10
1 is No improvement, 10 is Significant improvement
Describe any daily activities that are difficult without support.
Living Situation and Care Environment
Housing Type
*
Please Select
House
Apartment
Condo
Townhouse
Farm/Rural Property
Other
Are There Pets in the Home?
*
Yes
No
Yard or Outdoor Access
*
Private yard
Shared yard
No yard, but regular outdoor access
Limited outdoor access
Other
Household Members
Limitations That Could Affect Dog Placement or Care
Experience and Preparedness
Prior experience with dogs or assistance dogs
*
No prior experience
Limited experience with pet dogs
Experience handling pet dogs regularly
Experience with assistance dogs
Professional experience with dogs
Other
What tasks are you currently able to manage for a dog?
*
Feeding
Daily walks
Grooming
Veterinary visits
Basic training practice
Medication administration
Cleaning up after the dog
Other
How available is your daily schedule for training and handling responsibilities?
*
Very limited
1
2
3
4
5
6
7
8
9
Highly available
10
1 is Very limited, 10 is Highly available
Willingness to follow the placement and training plan
*
1
2
3
4
5
Dog Preferences and Matching
Preferred dog size
*
Small
Medium
Large
No preference
Preferred temperament
*
Calm
Friendly
Confident
Highly trainable
Independent
Patient
Affectionate
No preference
Preferred energy level
*
Low
Moderate
High
No preference
Preferred age range
*
Please Select
Puppy
Young adult
Adult
Senior
No preference
Special matching considerations or concerns
Submit Assessment
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