Service Dog Application for Disabled Veterans
Please fill out the following contract in order to participate in our Service Dog program.
Please select which type service dog applies to you: Application Process for Veterans with Service Connected Disabilities
Please all answer all required information before.
Note that we perform a background check on all applicants.
Completion of Application: • Please refer to checklist below to insure completion of application in its entirety.
*IF you are applying for a PTSD Dog, a Letter explaining the individual combat stressor including dates of the occurrence must accompany this application.
*Medical History must be completed by the applicant’s Medical or Mental Health Provider. Do not send medical records. The Medical History portion is NOT to be completed by applicant. The Provider’s office MUST send the Medical History portion of the application directly to Hounds and Heroes Service Dogs at the above contact options. **Medical History will not be accepted by any source other than Provider’s Office. PLEASE NOTE: APPLICANT’S DISABILITY MUST BE SERVICE CONNECTED, AND NOTED AS SUCH IN THE MEDICAL HISTORY PORTION OF THE APPLICATION.
Please use the following checklist to ensure all required items are completed and sent to Hounds and Heroes.
Part 1: Personal Information — complete and sign
Media Release — complete and sign
Acknowledgement — complete and sign
HIPAA Authorization for Release of Information — complete and sign
Two References Letters: include Name, Phone Number, and Address of Reference along with letters.
Part 2: Medical History- sign Provider’s Release, Download (last section) and send to Provider to complete
PTSD Letter of specific Stressor including Dates.
Letter from Mental Health provider confirming your involvement in mental health & group counseling.
Veteran Affairs compensation letter *For Mobility applications only
Copy of DD‐214
Questions regarding this process may be submitted via our contact form When did you serve and which combat zone deployment (including dates)?
*PTSD applicants will need to physically visit with a Hounds and Heroes, Inc. Trainer in your area. If a facility visit is not feasible, the applicant will need to be in contact with Hounds and Heroes and speak to the Veteran Coordinator who will discuss, in detail, the applicant’s options.
*For Mobility applications - Once a service dog is determined appropriate for the applicant, the applicant must be financially able to travel to Hounds and Heroes, Inc. trainer and afford accommodations during the transitional training phase with the service dog (approximately 10 days). Hounds and Heroes does not provide such things as attendant care, transportation, lodging, meals, etc. during this period.
Hounds and Heroes, Inc. will only review complete applications. A complete application is one that includes all the above requirements. A representative of Hounds and Heroes, Inc. will contact the applicant to clarify any issues, answer any questions, and advise the applicant of the next step in the process.
Prior to receiving a service dog; an
in‐home visit must be completed for all applicants. This involves a Hounds and Heroes, Inc. representative physically visiting the applicant’s home to meet with the applicant and any other individuals and/or animals that reside within the applicant’s home. The visit generally lasts anywhere from 1‐3 hours and will be scheduled by a Hounds and Heroes, Inc. representative at the availability of Hounds and Heroes, Inc. and the applicant.
Please note, sending in the application does not mean the applicant is automatically approved.
3+ months or more. The application MUST go before a committee and if successful the applicant is tentatively approved. It is crucial that the applicant send in all the items needed by Hounds and Heroes, Inc., and understand that the application process, from time of approval to placement, can take
Pre- Qualifying Questions
Are you willing to attend training in the LA County or in your area, at your own expense?
Are you willing to wait 3 plus months in order to receive a service dog?
Are you financially able to cover the expense of a service dog? (Vet visits, Food, Etc.)
Are you willing to submit to a background check?
PART 1: PERSONAL INFORMATION
This part of the application is to be completed by the applicant applying for a Service Dog.
Please note, branch of service, term of service, rank, and disability rating are for informational purposes only and are not factors used to determine eligibility for a Hounds and Heroes, Inc. service dog. DEMOGRAPHICS VETERAN STATUS Date of Service Connected Disability: EQUIPMENT REQUIRED
(Please check all that apply)
Define Disability (please be as specific as you can): Cause of Disability (please be as specific as you can): Define Specific Need for a Service Dog (please be as specific as you can): Cause of Disability (please be as specific as you can): Define Specific Need for a Service Dog (please be as specific as you can): PTSD SYMPTOM CHECKLIST
Please check all that apply
If there are other behaviors that are affecting you negatively, please explain below: HOME ENVIROMENT Please give the names and ages of people living in the home and/or taking care of the disabled veteran on a daily basis. STRENGTH ASSESSMENT
Rate your physical strength on a scale of 1 to 10 (1=Least and 10=Most). For example, if you have severe difficulty grasping a tennis ball, please put 1. If you have no difficulty grasping a tennis ball, put 10.
MEDIA RELEASE STATEMENT
Hounds and Heroes, Inc. uses electronic and traditional media (I.e. photographs, video, audio, testimonials) for publicity, social media and educational purposes. By my signature on this form, I acknowledge receipt of this document and give permission to Hounds and Heroes, Inc. and its designees to use such reproductions for educational and publicity purposes in perpetuity without further consideration for me. I understand that I will need to notify Hounds and Heroes, Inc. if any changes to my situation occur that will impact this media release permission.
I have read the above release and am aware of its contents. ACKNOWLEDGEMENT
Hounds and Heroes, Inc. is a non‐profit organization and relies on donations in order to place our service dogs. It takes approximately one and a half to two years to train a full-service dog at a cost up to $35,000; consequently, Hounds and Heroes must have the best interest of the service dog in mind when placing that service dog with an applicant.
Therefore, Hounds and Heroes, Inc. reserves the right to deny an applicant at any stage of the process in acquiring a Hounds and Heroes, Inc. service dog. We also reserve the right to remove a placed dog from a recipient if it is deemed necessary by staff.
**Additionally, in the event that the recipient should pass away within the first three years of the dog’s placement, it is at the discretion of Hounds and Heroes, Inc. to reclaim the dog or allow the family first rights of adoption within thirty days of recipients passing.
While Hounds and Heroes, Inc. does not anticipate any of the above‐mentioned problems, we must inform all applicants of these possibilities.
PROMISE OF PRIVACY TO APPLICANT’S PERSONAL HEALTH INFORMATION(PHI)
Hounds and Heroes, Inc. is fully committed to compliance with HIPAA guidelines, located at
Providing appropriate security for our service dog applicant’s (Applicant) PHI(Privacy Health Information).
Protecting the privacy of our Applicant’s medical information.
Providing our Applicant’s with proper access to the medical portion of their application.
Appropriately maintaining our Applicant’s information in compliance with national standards.
If you ever have any questions or concerns regarding an Applicant’s PHI please bring them to the attention of Hounds and Heroes.
PART 2: MEDICAL HISTORY
Download this form below. This Form must be completed by your Medical Provider.
Applicant/guardian must be provided with a signed copy of this authorization form Applicant must submit part two Medical History to their medical provider. The Provider’s office will send this section of the application directly to Hounds and Heroes, Inc. using the contact information on page 13 of form.
Hounds and Heroes, Inc. may request specific vital information pertaining to the applicant’s medical condition/disability.
DOWNLOAD MEDICAL HISTORY FORM Submit any requested documents below: Upload File
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