Name *

First Name

Last Name

Phone *

(###)

###

####

Is the disabled individual over 18? *

Yes

No

Parent/Guardian Phone

If applicant is under 18 or filling out on behalf of the disabled individual

(###)

###

####

What services are you interested in? *

Psychiatric

POTs

Autism

Puppy Service Dog Foundations

Which lesson format are you interested in? *

You may choose more than one

In Person

Hybrid

Virtual

Do you currently have a dog? *

Yes

No

Have you trained a service dog yourself before? *

Yes

No

Does your dog have any of the following:

Separation Anxiety

Crate/Confinement Anxiety

Hyperarousal/Cannot settle

Reactivity

Aggression