Sterling Service Dogs Inquiry Form

Inquiry Form/Begin Application Process INTERESTED IN A SERVICE DOG? THERAPY DOG? OTHER SERVICES? If you feel you would qualify for a service dog or therapy dog or other services and would like additional information, complete the following inquiry form. Applicants are screened to determine individual needs and the ability to benefit from a service or therapy dog or other services and to provide a safe and healthy living environment for the dog. To begin the application procedure to receive a Service Dog or Therapy Dog or to apply for Other Services, please fill out and submit this form. If you are unable to use this on-line form, please call us at 586-977-9716 to have an application form mailed or faxed to you.
First Name
Last Name
Street Address
City		State	Zip Code
E-mail address
Home Phone:
Date of Birth	Gender: Male Female
Height	Weight
Occupation
How did you hear about Sterling Service Dogs? Are you seeking a Service Dog Therapy Dog or Other Services If "other", please describe Describe your primary disability or health problem. Please identify any other physical, emotional or cognitive problems you live with. If applying for a child or adult, list the name, age, gender and disabling condition(s). If there is a speech or cognitive impairment, please describe. If you have a dog for which you are seeking services, please give the dog's name, breed, age, gender, size and the amount of training to date: Do you know someone who has a service dog? What does the dog do for that person? Please describe the various ways you feel a service dog or therapy dog could benefit you (or the person you are applying for) Describe any prior training experience you have with dogs Describe any animals (pets or livestock) that are part of your household Have you ever partnered with a service dog? If yes, please give details. Have you applied to other service dog programs? If so, how long ago? Do you use special equipment or assistive technology (i.e., cane, wheelchair, van with lift, walker, braces, speechboard, other devices). If yes, please explain. Describe other members of your household. Do you have an attendant? Describe your home (choose from the pull down list below) Your yard is Fenced Unfenced How do you get around town? (i.e. van, own car, public transportation, friends) please describe: Describe your home life, social activities, hobbies and lifestyle in general. Do you work or travel or go to school or volunteer? Describe a typical day in your life. After completing this entire form, click the SUBMIT button below. You will receive confirmation via e-mail