Assistance Dog pre-Applicant Questionnaire


Privacy Statement

Because we have a non-refundable $25 application fee, we request some initial information to determine if a person is eligible for a Circle Tail assistance dog before we start the application process. Please complete the following questionnaire and submit the results to Circle Tail.

Date:
Applicant Name:
Age of applicant:
Street Address:
City/State/Zip:
Home phone:
Work phone:
Cell phone:
*Email:
(that you check)
  

* Please note that our preferred method of communication is by email. Some spam filters may delete emails that come from Circle Tail. If you have not received a response within 5 business days, please email or call us to follow up on your pre-applicant questionnaire.

Do you live within 75 miles of Circle Tail or within Ohio?   Yes No
Description of disability:
How long have you had the disability?:
Is your disability stable?  If not, please describe recent exacerbation in your condition.
If you have a psychiatric disability, is it currently controlled with medicine?
Describe at least three tasks you would want your dog to do for you?
How many people in the house and ages?
Do you or anyone in your household smoke?   Yes No
If Yes, what is the frequency and location that you smoke?
What is the frequency and location that others in your household smoke?
Number and type of pets in the home (please note, we generally do not place assistance dogs in homes with young or adult dogs. Exceptions may be made for homes with senior dogs.)
Living arrangements (apartment, house with fenced yard, etc.)
Are you able to financially support the dog?
Describe how your dog will receive exercise?
Are there two family/friends in the community that would provide short-term care for your assistance dog if an emergency occurs?
Do you work?
How do you travel to local places?
Are you able to travel to Circle Tail for an initial interview and for the required 60 hours of training and partnership process?

Thank you for completing the pre-applicant questionnaire. A Circle Tail Assistance Dog Committee member will contact you within 5 business days regarding your questionnaire.

Please input text from image bellow:


Circle Tail, Inc.
8834 Carey Lane
Pleasant plain, OH 45162
513-877-3325