Client Name *

Referred By

Email *

Phone *

Address *

Marital Status *

Gender Identification *

Who lives in your house? *

Do you have support in obtaining a service dog from all members of your home? *

Do you have other pets in the home? *

Do you have a fenced backyard? *

Are you a first Responder? *

Service

Have you previously owned dogs? *

Have you had a service dog previously? *

Did you obtain professional training? *

Emergency Plan for dog care if you are not capable of caring for the dog yourself? *

Give an example of how you resolve conflict within your general life: *

Select all that apply to the level of your comfort.

Do you have a diagnosis from a qualified professional? *

Do you have support from your professional to obtain a service dog? *

Do you have mobility issues? *

Which tasks do you believe the dog will help you with?

Do you have transportation to weekly class within the St. Thomas area? *

Will you agree to follow the rules and guidelines as set out by The Phoenix Canine Initiative (Quest Canine Services Inc)? *

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

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