In Home Service/Hearing/Companion Dog

General Information


An In Home service or hearing dog is a dog that is trained in specific service or hearing dog skills such that they can perform the skills in the home for a person with a disability. An In Home companion dog is a dog that is provided to a family that has a child with a specific need because of a disability.

An In Home service, hearing, or companion dog may be right for you and/or your family member if:

  • You have a disability and would benefit from some extra assistance in the home while others are gone, but you typically have family or friends that accompany you when you are out.
  • You have a hearing impairment and manage just fine with hearing aids but don’t want to wear them when you are home.
  • You have a child with a disability who would benefit from the calming presence of a dog and his/her companionship.
  • You have a pre-teen (10+) or teen with a disability who would benefit from a task trained dog but is not yet ready for the responsibility of a public access service/hearing dog.

If you think an In Home service, hearing or companion dog might be right for your or a family member, please complete the In Home Service/ Hearing/ Companion Dog Application below. Once we receive this form, we will contact you for a phone interview. In most cases we will have you come to Circle Tail for an interview so we can gather more information on you or your family member's needs.

In Home Service/Hearing/Companion Dog Application


Use this form to apply for a Circle Tail In Home Service/Hearing/Companion dog for yourself or a family member. We are requesting this information to guide us in making the best match between you, your family and one of our dogs.

Please complete all questions, read the "In Home Service/Hearing/Companion Dog Adoption Agreement" that follows the questions and submit the form to Circle Tail.

Please note, besides this application, we will have a phone conversation, an interview at Circle Tail, and a home visit for the potential recipient and family. Training will be required prior to and following placement of the dog. The amount of training will depend on the team’s needs.

Here is our ----> Privacy Statement

Application



All Fields are Required. Use NA, if not applicable.

Date: (click on field for calendar)

Name of Applicant: Age:
(The Applicant is the person needing an In Home dog.)

Street Address:

City & State:   Zip Code:

Primary Phone: Cell Phone:

Email Applicant regularly checks, if any:

Name of Person Completing Application: Age:

Relationship to Applicant:  

Primary Phone: Cell Phone:

Email that you regularly check:



Does the Applicant live within 75 miles of Circle Tail or within Ohio?   Yes No

Description of disability:

How long has the Applicant had the disability?

Is the disability stable? If not, please describe recent exacerbation in condition.

Describe Applicant’s limitations in detail including verbal/hearing/cognitive/mobility/mental health, etc.

List the activities you expect a service/hearing dog to help Applicant with.

What are the 2 most important activities for which help is needed?

Is there an outside caretaker involved with Applicant’s care?
If so, please explain the duties of the caretaker.

Dog Gender Preference:   Male Female No Preference

Dog Size Preference, check all that apply:
Small (15 - 30 lbs)
Medium (30 - 60 lbs)
Large (60 - 90 lbs)
No Preference

Breed Preference:

Indicate any breeds you do not prefer:

What breed(s)/ type(s) of dogs have you had responsibility for as the primary caregiver, and how long did you have each of them?

What pets live in the home currently (please include names):

Veterinarian's Contact Information:

Vet Name & Address:

Vet Office Phone:

Number of people in household, including Applicant:

Ages of children under 18 yrs. old in household:

Who will be the dog's primary caregiver:

Does the Applicant or any family members/caretakers smoke?

Does any other person in the home have any mental health or physical disabilities? If yes, please describe.

Applicant lives in a:   Town/City Suburb Rural Area

Applicant resides in a:   House Mobile home Apartment Condo

If Applicant's housing is rented, please provide the following information.
Please insert NA in each box, if you do not rent.

Landlord Name:
Landlord Phone with Area Code:

Is yard for dog fenced:   Yes No   (If no fence, insert NA in the following 3 questions.)

If yes, approximate square feet fenced:
If yes, is fence solid, wire or electric?
If fence is solid how high is it?

If Applicant's household will have visitors over, check all that apply:

All the time -- household has a revolving door
A lot
Sometimes - occasional friends and family over
Rarely - doorbell doesn't work

Comments:

Dog should like to exercise:

Hardly at all - "couch potato"
Moderately - 30 - 40 minute walk per day, playing fetch, etc.
A lot, a running/hiking partner
Other

Comments:

Number of hours per day the dog will be routinely left alone:

Describe where the dog will be when the Applicant is not home:

Describe where the dog will be when the Applicant is sleeping:

How much training is the Applicant willing to do?

Do not want to do training
Willing to do some training
Willing to do a lot of training

Comments:

Does the Applicant mind house training a dog? (understand any dog may have accident or two while adjusting to new environment)   Yes No

Comments:

Is the Applicant comfortable doing training with the dog to improve manners such as jumping, stealing food, and pulling on the leash, etc.?   Yes No

Comments:

Is the Applicant comfortable doing training with the dog to maintain/improve obedience and advanced skills?
Yes No

Comments:

How much is expected to be spent yearly for the care of the dog, including food, medical care, boarding, grooming, toys, heartworm, and flea control, etc.? per year.

How will the Applicant provide DAILY exercise (at least one hour per day) for the dog? Please consider living arrangements, physical condition, and seasonal weather conditions.

In Home Service/Hearing/Companion Dog Adoption Agreement


I have read this form and by signing below, I understand and agree to the following:

  1. I am adopting an in home service/hearing/companion dog. This dog will provide assistance to me/my family member in our home and will be the only dog in the home during the working life of this dog.
  2. This dog will not wear a service dog vest or be taken in places of public accommodation where pets are not allowed.
  3. I will keep this dog in accordance with local regulations. I will have him/her licensed within 30 days and then yearly.
  4. I will provide this dog with proper shelter, adequate food and water, and medical care to maintain his/her health and well-being. I will be personally responsible for the humane care of my in home service/hearing/companion dog.
  5. I will establish a schedule of preventative and routine medical care with a veterinarian.
  6. I will obtain immediate veterinarian care if the dog becomes sick or injured.
  7. I have been advised to take my new dog to the veterinarian within 2 weeks of adoption at my expense. I understand that all additional vet care following adoption is my financial responsibility.
  8. If the dog proves to be in such poor health that major treatment is necessary within the first month, I may return the dog for a refund of the adoption fee or proceed with the treatment at my own expense.
  9. I will practice and maintain the dog’s obedience and service/hearing/companion dog skills. Circle Tail welcomes any questions about the care of the dog, training or any behavioral issues that arise during the lifetime of the dog.
  10. This dog will not be sold, traded or disposed of, and if I can no longer care for him/her, I will consult Circle Tail about alternative placement.
  11. This dog will not be used for any experimental purposes.
  12. A representative from Circle Tail may visit the dog with prior notice. If not satisfied with the dog’s living conditions or appearance, Circle Tail may reclaim the dog.
  13. Within one month of the original adoption date, this dog may be returned to Circle Tail for any reason and the adoption fee will be refunded.
  14. I agree to assume full legal and financial responsibility for any property damages or personal injury caused by the dog after the adoption and to indemnify and hold Circle Tail harmless from any liability with respect thereto.
  15. Circle Tail, Inc. reserves the right to resume ownership of the dog if the above conditions are not met.

Is the Applicant able to travel to Circle Tail (north east side of Cincinnati) for an interview and/ or any training sessions that may be required prior to and following partnership with an In Home Service/Hearing/Companion dog?
Yes No

If there is additional training required for the In Home Service/Hearing/Companion dog, it is agreed the training will be completed at Circle Tail (or as otherwise directed).
Yes No

By typing "yes" in the following box and submitting this document, I affirm the foregoing questions have been accurately answered and I agree to all foregoing terms and conditions:

Please provide any additional comment you wish:

Input text from image below:


Please click the Submit button only once. It takes a few seconds for the form to be processed.

The following three things will happen next:

1. You Will See a Thank You Page.

If you have completed all required fields, once you click Submit, you will see a Thank You page. If you have not completed all required fields, you will be asked to complete the required fields before the form can be submitted and you see the Thank You page. Use NA, if a field is not applicable.

2. You Should Receive an Auto-Response Email.

If you have completed all required fields, once you click Submit, you and Circle Tail will be sent an auto-response email containing the information you supplied for the form. If you do not receive the email, please click the back button on your browser and make sure your email address is correct and click the Submit button again. Also check your spam or junk mail folder.

3. Within Two Days You Will Get an Email Acknowledgement from a Circle Tail Volunteer.

Please be sure to check your spam or junk mail folder as well as your inbox. If you do not get an email from a Circle Tail volunteer, please email admin@circletail.org.

We would appreciate knowing the details of the difficulties you had, so we can correct problems. Please email us at admin@circletail.org.

Circle Tail, Inc.
8834 Carey Lane
Pleasant Plain, OH 45162