Assistance Dog Pre-Applicant Questionnaire - Circle Tail

Most fields are required. If a required field does not apply, insert NA.

Name *

First

Last

Age *

Phone (Primary) *

Phone (Secondary)

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

How did you hear about Circle Tail?

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?

Yes
No

Please describe any recent exacerbation in your condition.

Do you have a psychiatric disability?

Yes
No

If yes, is it currently controlled with medicine?

Yes
No

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?

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
House without fenced yard
Other

If other, please describe

Are you able to financially support the dog?

Yes
No

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?

Yes
No

Do you work?

Yes
No

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?

Yes
No

Please add any additional comment.

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.

Custom Captcha *

=

this is widget test