Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
What is your professional role?
Where do you work?
How long have you been employeed?
Do you have plans to retire or move jobs in the next three years?
What is your readiness to have a facility dog? (e.g.: Immediately, 3 months, within a year,)
Who would the facility dog live with (yourslef or co-worker)?
Who will be the primary handler of the facility dog?
Is your employer or supervisor aware of and supportive of bringing a facility dog?
What type of facility or setting would the facility dog be used in (e.g., hospital, school, therapy center, community program)?
Who are the primary individuals or populations you serve (e.g., children, trauma survivors, clients with mental health needs)?
Please describe the environment where the facility dog would be working. (e.g., busy clinic, classroom, one-on-one therapy office, outreach program)
What daily activities and interactions would the dog typically be involved in?
Are there any known restrictions or limitations in your workplace (e.g., allergies, safety policies, space concerns)?
Are there any potential challenges you anticipate in bringing a dog into your setting?
What is your primary goal in integrating a facility dog into your workplace (e.g., improving engagement, reducing anxiety, supporting therapy sessions)?
How do you envision the dog assisting in your work? (e.g., providing emotional support, calming clients, encouraging participation, bridging communication)
How do you plan to incorporate the facility dog into your sessions or services? (e.g., present during group activities, used in de-escalation, support during transitions)
Will there be any co-handlers or other staff responsible for assisting with the dog’s care and handling during work hours?
Is there a fenced area where the dog can relieve itself and exercise? If not, is there another suitable area for this?
Do you have any prior experience working with dogs or other animals professionally or personally?, If so, explain.
Will there be any co-handlers or other staff responsible for assisting with the dog’s care and handling during work hours?
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 in your household have a disability? If so, please share any details you feel comfortable providing.
Do you have other pets? (If yes, please list species, breed, age, spayed/netuered and temperament.)
Do you own or rent your home?
If not, are your able to fence it.
Do you have a fenced yard?
How would you describe your home environment (e.g., quiet, active, structured, unpredictable)?
Do you have a support system in place to help with the care of the dog?
How many hours would the dog be left alone when not working? (Please note: Facility dogs do not have the same public access rights as service dogs. When not working, facility dogs are only allowed in places where pets are allowed.)
Please describe how you would provide exercise for the dog at home.
Why do you believe a facility dog is the right fit for your setting?
Do you have any concerns about introducing a dog into your work environment?
Is there anything else you’d like to share about your goals or needs for a facility dog?
