4 Paws for Ability | Alzheimer's Client Application

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Record Type

Alzheimer's Assitance Dog Application

This application is for individuals with Alzheimer's or other forms of dementia and who are, or are preparing to, no longer be independent. This placement is a three unit team with the primary handler being a spouse or other caregiver who lives in the home. This application can be completed by the person with Alzheimer's or by their caregiver. Please carefully fill out this application, only fully completed applications with submitted health forms and reference letters will be processed. Upon receiving your application you will receive an email receipt with links for the additional needed forms! This email will be going to the email provided in the first section of the application.

Once all components of an application have been received, the application will be processed. Upon acceptance the recipient is required to contribute a fee for service to 4 Paws. Most individuals meet the contribution requirement through fundraising. After you have reached your fee for service, you will be placed in a spot in the next open placement training class to receive your service dog. Currently these classes are full about 2 - 2.5 years out.

Client Personal Information

All of the contact information under the Client will be the primary way that 4 Paws contacts you regarding the application process as well as communication going forward.

Client First Name

Client Last Name

Street Address

City

State (please use 2 letter abbreviation)

Zip Code

Country

Primary Phone

Secondary Phone

Email (This will be the primary form of communication with 4 Paws and will be called your On File Email Address in the future)

Date of Birth

Are you a Veteran?

No Yes

This field is required

If you are a veteran, what War of Operation were you part of? (If applicable)

If you are a Veteran, please describe your time & role in military

Emergency Contact Information

Emergency Contact's Name

Emergency Contact's Phone

Alternate Emergency Contact's Name

Alternate Emergency Contact's Phone

Spouse/Caregiver's Information

Spouse/Caregiver's First Name

Spouse/Caregiver's Last Name

Primary Phone

Street Address

City

State (please use 2 letter abbreviation)

Zip Code

Date of Birth

What is the relationship of this person to the client?

Spouse

Relative

Friend

Caregiver

This field is required

If the caregiver is not a spouse, please describe the relationship

Medical Information

Physician Information

May we contact the Physician?

No Yes

This field is required

Physician's Name

Mailing Address

City

State (please use 2 letter abbreviation)

Zip Code

Phone

If Applicable

Physical Therapist's Name

Phone

Occupational Therapist's Name

Phone

Diagnosis

What is your primary diagnosis?

What other medical conditions do you have?

How does this affect your daily living skills? What are your limitations?

Do you have any restrictions or precautions as a result of your diagnosis?

What type of medical treatment are you currently receiving?

What medications are you currently taking and what are they for? (Please list name and use for each)

What types of adaptive equipment do you use? (ie. Wheelchair, crutches, hearing aid)

Do you have a psychiatric diagnosis?

No Yes

This field is required

If yes, please describe psychiatric diagnosis

Are you on medication to assist with a psychiatric diagnosis?

No Yes

This field is required

Insurance

Service Dog Certification

To be the handler of the service dog, the individual must be capable of making 100% correct choices for themselves and the service dog to the same capacity of an adult. Alzheimer's Assistance Dogs are placed on a three unit team (Spouse/Caregiver, Client, and Service Dog) and the Spouse/Caregiver must be present with the team in public. A service dog is not able to use higher judgement and determine things that may be "right" or "wrong" (ie. don't touch the stove if it is hot, lead a person who is confused back home, etc.) The service dog is a tool for a spouse/caregiver to use to help with task trained calming, comforting, and redirecting behaviors as well as safety measures if needed to prevent wandering through tethering out in public and/or search and rescue to lead a spouse/caregiver to the lost partner.

What tasks do you think a service dog could do to help in your situation?

Why do you want a service dog?

Employment Information

Are you employed or volunteer?

No Yes

This field is required

Employer

Address

City

State (please use 2 letter abbreviation)

Phone

Basic Job Duties

May we contact your employer?

No Yes

This field is required

Spouse/Caregiver's Employment Information

Employer

Address

City

State (please use 2 letter abbreviation)

Zip Code

Employer Phone

Basic job duties

May we the contact Spouse/Sponsor's employer?

No Yes

This field is required

Household Information

Type of Home

Other House Apartment

This field is required

If you chose the type of home as other, please explain

Do you own or rent your home?

Rent Own

This field is required

If you rent, please list your Landlord's Name

If you rent, please list your Landlord's Phone

Do you have a fenced yard?

Partial No Yes

This field is required

If your yard in not currently fully fenced, is this something you plan to do?

No Yes

This field is required

If you will not have fence, do you have access to a fully fenced in area where you could exercise a dog?

No Yes

This field is required

Please describe how you will provide exercise for the dog

Please list everyone who resides in the home, including their Name, Age, and Relationship

Pets & Veterinary Information (Past & Present)

4 Paws for Ability requires that all pet dogs within the home are: up to date on vaccines, receive monthly heartworm medication, friendly towards other dogs, inside dogs, and that the number of dogs in the home does not exceed three dogs by the time that the service dog would be placed in the home. Applicants understand that they are agreeing to not add any additional pet dogs to the home from now until at least one year after the service dog is placed to give the service dog time to adjust and bond appropriately.

Are there currently pets within in the home?

No Yes

This field is required

Please list all pets that live in the home, including their Species, Name, Age, Sex, size and whether they are spayed or neutered

Do they live inside?

No Yes

This field is required

If not, where do the outside pets reside?

If these are current pets, are they up to date on all vaccines?

N/A No Yes

This field is required

If not all pets are up to date on vaccinations, please explain why

If you currently have a dog, is it on heartworm preventatives?

N/A No Yes

This field is required

If your current dog is not on heartworm preventatives, please explain why

Please list past pets and why you no longer have them (If they have passed away, please include age and cause of death. If they were rehomed, please include reason)

Veterinarian

Veterinarian's Practice Name

Veterinarian's Phone

How long have you used this veterinarian?

Service Dog Information

4 Paws for Ability requires that families maintain a high level of care with their service dog. It is expected that your dog will be fully up to date on all medical care, provided a high quality diet, maintain a healthy weight and be properly groomed. To accomplish this expectation requires a family to be prepared for a cost around $1,500-2,000 each year.

Are you financially prepared to care for the service dog?

Other No Yes

This field is required

Can you physically bathe and groom the dog?

No Yes

This field is required

If not, are you financially prepared to pay for grooming?

No Yes

This field is required

Please explain financial situation if you answered "no" or "other" to any of the above

How many years do you expect to care for the dog?

Service Dog Handling

Is the caregiver physically able to independently handle the dog?

No Yes

This field is required

If they are not, who will handle the dog for you?

What help would be needed in handling the service dog?

Who will handle the service dog in public?

Who will handle the service dog in the home?

Explain the handler situation and list all who would potentially handle the dog

Please explain the thoughts of the rest of the family and what they believe the potential benefits of having the service dog would be

Anything else you want us to know?

I understand that upon acceptance into the 4 Paws for Ability program, I will need to meet my fee for service which is my contribution towards the cost of the breeding, raising, training and placing of the service dog.

No Yes

This field is required

I understand that after I have met my fee for service, I will be placed in the next open placement training class to receive my service dog which can be at least 2 - 2.5 years out due to class availability as well as the time it will take 4 Paws to breed, raise and train my service dog.

No Yes

This field is required

I am willing to sign a contract.

No Yes

This field is required

4 Paws reserves the right to deny services to any applicant which doesn’t meet the
criteria necessary for placement of a service dog or who requires services not
trainable within the guidelines of the agency.

Contact info:

Jennifer Lutes

jennifer@4pawsforability.org

(937)374-0385

www.4pawsforability.org

Full Name

Today's Date

$50 Nonrefundable Application Fee Due in order to submit Application

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$50

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If you have trouble with the payment section on the next page, please submit your application payment using the following link to ensure that your application is reviewed and sent to the next steps.

Please ensure the client's name is entered as well as the same email address used on your application. Thank you!

https://www.4pawsforability.org/client-application-fee/

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Please contact mattfrederick@4pawsforability.org if you have questions about a form

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