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Page 1

Autism Service Dog Pre-Qualification Form

Child's Name and Age (Individual with Autism)

First Name

Last Name

What is your child's age?

Applicant's Name and Age (Third-party handler of service dog)

First Name

Last Name

Age of Legal Guardian

Contact Information

Phone

Country

Address Line 1

Address Line 2

City

State

Province

ZIP / Postal Code

HIDDEN FIELDS

Lead ID

Lead ID Populated?

Page 2

Does your child have a diagnosis of Autism?

Yes

Are you (third party handler applicant) currently employed full time outside of the home? Applicants must be able to prove utilization of an autism service dog.

Yes

If employed, describe your occupation, and provide your weekly work schedule.

Does your child like dogs?

Yes

Are you or another household member allergic to dogs? (There are currently no hypoallergenic dogs in the service dog program. We encourage you to explore AssistanceDogsInternational.org to find other programs that can meet your needs.)

YesNo

Describe in detail previous interactions your child has had with dogs

Are you able to afford the costs of caring for a service dog to include food, equipment, supplies and veterinary care for the lifetime of the dog, an average of $50-$200/month?

Yes

List all pets in household (include species, breed & age)

Are you able to leave your family and travel for a week in order to participate in a classroom/ group setting for Team Training?

Yes

It is a requirement that our dogs are always supervised by their handler or safely crated. They are not allowed to have free run of the house or put outside because that gives them an opportunity to practice unwanted behavior which can affect their effectiveness as a service dog. Our service dogs cannot be crated for longer than 6 hours and for more than one day at a time, as this will affect their overall utilization and ability to work. Can you meet these requirements?

Yes

TLC uses only positive reinforcement training methods. A service dog’s training must be maintained by their recipient. If selected, are you willing to use only positive reinforcement training methods and actively participate in the dog’s ongoing training, annual assessments and health checks for the working life of the dog?

Yes

Is your child receiving ABA therapy, speech therapy, occupational therapy, or some other type of therapy or support services related to your child’s diagnosis of autism?

Yes

Page 3

Select all items that apply

My child has repetitive behaviors that need interrupting.My child is non-verbal.My child elopes.My child has physical or mobility limitations.My child has sensory processing challenges.My child requires assistance feeding.My child requires assistance toileting.My child requires assistance dressing.My child has frequent tantrums/meltdowns.My child takes medications.My child uses augmentative devices to communicate.My child is home schooled.My child's therapies take place in school.My child's therapies take place outside of school.

Please provide detailed information on any items checked, as well as any additional information relating to your child’s symptoms.

List all household members. (Include age & relation)

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