If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Applicant Name * Street Address City, State Home Phone Cell Phone Email * Date of Birth Age Height Primary diagnosis for which I'm applying for a service dog * Provide details: Mobility Assistance Psychiatric Assistance Seizure Alert/Response Please provide details If you are applying for a Psychiatric Service Dog, do you wish to take part in the Co-Train program? www.buckeyeservicedogs.com/operation-co-train/ YesNo Living Arrangements Apartment Condo Assisted Living Independent Living Rent my home Group home Other Please list the people living in your home Name / Age Name / Age Name / Age Is anyone in your home... Allergic to dogs?Afraid of dogs? Please tell us about any pets in your home Name / Species / Age Are any dogs or cats in the home aggressive? No Yes Have you ever owned a dog before? Yes No Upper Body: Please describe any difficulties you have with your arms, hands, shoulders, neck, head, etc. Lower Body: Please describe any difficulties you have with your legs, your balance, or ambulation. Please describe any cognitive challenges or limitations you have due to a brain injury, birth defect, medication or other issue. Please describe any psychiatric challenges you are facing (PTSD, Anxiety, Depression, etc.) which significantly impair your ability to interact in the community and/or with people. If you have a seizure condition, please describe the type and frequency of your seizures. Please list all hospitalizations you have undergone over the last 18 months, including their duration and the reason for the stay. List the ways you would most benefit from a service dog to help you become more independent. Describe to the best of your ability your ideal service dog (breed, color, size, sex, personality). Describe to the best of your ability what you do not want in a dog. In addition to the fees you pay Buckeye Service Dogs, a dog costs an average of $1,000 to $1,500 per year for food, veterinary care, grooming and other expenses. Are you prepared to take on this ongoing expense for the rest of the dog's life? Yes No Do you have any previous experience with service dogs or animal training? Yes No If you have had a service dog in the past, where did you obtain the dog? Please explain why you are interested in working with a service dog: Will your dog travel with you? Always Somtimes Never Do you plan to take the dog with you to work and/or school? Always Somtimes Never Will the dog be going on daily errands? Yes No Please list your current employer if applicable Employer / Phone May we contact your current employer? Yes No Do you receive any social services? If so, please describe. Agency / Phone / Address / Contact I have read the Fee Section of Buckeye Service Dog's Website and I understand that BSD's typical fees range from $13,500 to $16,000 per dog, depending on my needs and location. * Briefly describe your plan for payment How do you plan to pay for your dog? I receive an IO waiver from DODD. I receive a Level 1 waiver from DODD. I receive services from BVR. I have a home care waiver. I will be engaging in fundraising activities I intend to self-pay. I understand this involves three payments over a 6-8 month period. Have you ever been convicted of a felony? If so, please describe. Have you ever been convicted of animal abuse/neglect? If so, please describe. Please list three people we may contact as references that do not live with you. * Name / Phone The next step in the application process is an assessment appointment. Would you like to schedule an appointment? YesNo thanks If not, why not? Please note that an Assessment Interview is necessary to move forward with your application. If you are applying for a dog on behalf of the applicant or assisting them with this application, please provide your contact information: Your Name: Phone Number: Email: Relationship to the Applicant: How did you hear about Buckeye Service Dogs? What is thirteen minus 6? *
