New Client Questionnaire

Thank you for taking interest in Confident Canines Service Dog Program. Before we can assist you with training you service dog prospect, we have some questions that we need to ask. Your answers will be kept confidential, please be as detailed as possible so we can assess your disability needs. If you don't know how to answer the question, don't worry, we can talk about it further. If the question is not relevant to your situation, just write N/A in the space.

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Are you a First Responder? *

If so, whice service? *

Do you have a formal diagnosis of PTSD or any other mental health condition?. (If so, please provide supporting documentation from your health care professional. *

What treatments are you currently using to assist with the symptoms of your mental health? *

What other conditions, challenges or disabilities do you have that you believe a service dog could assist you with? (arthritis, hypermobility, an imbalance due to TBI, vision loss, etc) *

Do you have the support of your current healthcare provider to add a service do to your current treatment plan? *

Do you have a letter of medical necessity for your need of a service dog? *

Are you currently searching for a dog to train as a service dog? *

Do you need assistance with choosing an appropriate service dog candidate? *

Have you identified what breed of dog you would prefer to use as a service dog? *

If you own a dog was it purchsed as a trained service dog? *

If you purchased a trained service dog, where did you purchase your dog? *

Do you have any other pets or service animals in the home? *

If yes, please list the animals in your home, ages and breeds and species. *

Do you currently own a dog that you wish to train? *

If so, please answer the following questions.

Breed of Dog: *

Age: *

Is this a dog/puppy you wish to have trained for service? *

If your dog is 5 months old or older, what organization/service did you begin your training? *

What method or style of training was utilized? *

If you own a guarding breed, have you done any protection work with the dog? *

Is this a rescued military dog? *

If you currently own a dog and are seeking additional training, what are some of your current concerns, what are you struggling with? What are your training goals? *

If you own your dog have you passed the Canine Good Neighbour Test (CGN)? *

Please provide where and the date you passed your CGN test. *

Please list what tasks you would like your service dog to learn? *

Can you attend activities outside of your home by yourself? For example: Grocery shopping, medical appointments, social outings. If not, please describe how you are currently assisted with these activities: *

Do you have access to transportation to training sessions? *

Are you comfortable training with a group of people or are you looking for private lessons? Are you open to both? *

What is your availability for training? Weekdays, Weekends? Daytime, afternoon or evenings? *

Please explain you understanding and knowledge of the laws that would impact you as a service dog handler in New Brunswick. *

Have you worked with any programs, organizations, or trainers in the past? If so please list: *

How did you hear about Confident Canines Service Dog Program? *

Is there any additional information you care to share or we should be aware of? *

References

Reference 1

Name *

Relationship *

Phone Number *

Email *

Reference 2

Name *

Relationship *

Phone Number *

Email *

Submit

In partnership with K9 Country Inn Working Service Dogs

New Client Questionnaire

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