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Psychiatric/PTSD
Service Dog Training Application
(Client Form A1)

For applicants who need a Service Animal for Psychiatric/PTSD needs, there are two additional application forms:

  1.) Psychiatric/PTSD Service Dog Application - (Client Form)

  2.) Psychiatric/PTSD Service Dog Application - (Mental Health Provider Form)

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NOTE:  YOU MUST COMPLETE PART A, B AND C OF THE SERVICE DOG FORMS FIRST.

Date of Birth
Month
Day
Year
During the past 4 weeks have you had any problems with your work or daily life due to your physical health?
During the past 4 weeks, have you had any problems with your work or daily life due to any emotional problems, such as feeling depressed, sad or anxious?
Overall how would you rate your mental health?
Excellent
Somewhat Good
Average
Somewhat Poor
Poor
Not Sure
Have you felt particularly low or down for more than 2 weeks in a row?
Very Often
Somewhat Often
No So Often
Not At All
During the past two weeks, how often has your mental health affected your relationships?
Very Often
Somewhat Often
Not So Often
Not At All
Calm and Peaceful
Never
Once In A While
About Half the Time
Always
Energetic
Never
Once In a While
About Half the Time
Always
Gloomy
Never
Once In a While
About Half the Time
Always
Angry
Never
Once in a While
About Half the Time
Always
Have you ever been diagnosed with a mental disorder before?
Yes
No
When did you last get your mental health examination done?
Less than 6 months ago
6 months ago
A year ago
More than a year ago
Is there a history of mental disorder in your family?
Yes
No
If YES, Please select which of the family members has/had a history of mental illness.
Light physical Activities
Very Less
Moderately
Very Much
Most of the Time
Heavy Physical Activities
Very Less
Moderately
Very Much
No Problem
Have you seen a therapist in the recent past?
Yes
No
Are you currently taking any medications?
Yes
No
How many hours do you sleep per day?
Less than 4
4-6
7-9
9+
How is your quality of sleep?
Very bad
Bad
Normal
Good
Very good
How often do you feel positive about your life?
Never
Occasionally
Frequently
All the time
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