Your Name
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First Name
Last Name
Are you:
Email
*
Phone
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Name
First Name
Last Name
Date of Birth
MM
DD
YYYY
Age
When were they diagnosed with autism?
Can you briefly describe your child’s main challenges related to autism?
Does your child attend school? If so, where?
Would you like the dog to accompany your child to school? If so, has this been discussed with the school?
Please describe your plans for your child’s future education.
Has your child spent time around dogs? How do they typically respond?
What specific needs or behaviors are you hoping a service dog will help with?
Are you looking for support with elopement (wandering/running off)? If so what is your child’s current weight?
Does your child experience sensory overload or meltdowns? How often? How long do they typically last?
What typically triggers these episodes?
What does your child usually do during a meltdown or sensory overload?
Do you or your child use any coping mechanisms or tools to help during these times? (e.g., sensory toys, noise-canceling headphones, breathing techniques)
Which therapies is your child currently receiving (e.g., ABA, speech, OT), and how long have they been participating in each?
Has your child participated in any therapies in the past? If so, please list them and include the duration of each
What therapeutic goals are you currently working on?
Have you discussed the idea of a service dog with your child’s therapist or healthcare provider?
Does your child live with both parents/guardians or primarily with one parent/guardian? If split, please describe how time is typically divided between homes.
Are both parents/guardians supportive of getting a service dog for your child?
Will one parent/guardian (or both) be trained to handle the dog? If both, who would be the primary handler)?
Parent/Guardian #1 Employer:
Parent/Guardian #2 Employer:
Would either parent be able to take the dog to work during the day? If yes, which one?
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Who lives in your home? Please include names, ages, and relationships.
Does anyone else living in your home have a disability? If yes, please describe as you are comfortable.
Do you have other pets? If yes, please list species, breed, age, spayed/neutered and temperament.
Do you own or rent your home?
Do you have a fenced yard? If yes, please give dimensions.
If no fence, would you be able to install a fence?
How would you describe your home environment? (e.g., quiet, active, structured, unpredictable)
Where would the service dog be during the day if not with your child?
How many hours would the dog be left alone?
Please describe how you would provide exercise for the dog?
Do you have a support system (family, friends, caregivers, professionals) that helps with your child’s care or could assist with a service dog?
Who are the primary people in your child’s life that provide care or support?
Would these individuals be able to help with the daily care, training, or supervision of a service dog if needed?
Are there any other details about your child, family, or home situation that you feel are important for us to know regarding a potential autism service dog.
Use this space to tell us anything else that would help us understand your child’s needs and how an autism service dog could assist.
