Psychiatric/PTSD Mental Health Provider

Psychiatric Service Dog Mental Health Form

Your provider can either complete and submit this form online or you can download and print the pdf file and submit it to us via email.

Dear Provider,

Your Patient (Name of Patient)

Date of Birth

Month

Day

Year

Your patient has applied to Paws For Life USA for a psychiatric / PTSD service animal. Your patient has completed the attached Consent Form authorizing you to share information regarding your patient's psychiatric / PTSD and/or other related diagnosis for mental health in relation to our service animal program.

In order for us to consider their application, please provide us with the information requested in the Mental Health Form.

All of the psychiatric / PTSD applicants in our Paws For Life USA program must provide us with written information confirming their diagnosis from a psychiatrist or psychologist qualified to make the diagnosis.

Date of Mental Health Diagnosis:

Month

Day

Year

Diagnosed by:

Qualifications:

The following is to be completed by the Patient's Mental Health Provider (Psychotherapist, MHY Nurse, Registered Social Worker, VA or other qualified professional with experience in Psychiatrics / PTSD or Mental Health).

Providing us with information will help us to “customize” our support to the client and increase our understanding of the specific disabilities that they have.

Our program is challenging for some clients and it means a commitment to attend training on a regular basis, either in person or virtual, more so in the early stages of training, but as disabilities vacillate, basically it will be for the working life of the animal, with the first 2 years being predominantly the hardest challenge for the team.

Paws For Life USA has a 24/7 commitment to the working life of the service animal to be there for the team, to encourage and provide the support needed, with the objective of gaining independence, the ability to feel secure and be able to socialize in today’s environment.

Paws For Life USA strives for a successful partnership with our animal placements. Therefore, we ask that you complete this report and summarize the state of the applicant's mental health and treatment. If you have any questions about our program, please contact Mike Alexander or Kimberly Brenowitz at Admin@pawsforlifeusa.org.

Paws For Life USA, a 501c3 non-profit

Cell: 770-402-0297

Fax: 770-579-8289

Tax ID#: 86-1094919

Mailing Address: P.O. Box 72016, Marietta, Georgia 30007-2016

School Address: 3100 Roswell Road, Ste 125, Marietta, GA 30062

Website: https://www.PawsForLifeUSA.org

Like us on Facebook: https://www.facebook.com/pawsforlifeusa

MENTAL HEALTH REPORT

Is your patient currently receiving psychiatric treatment or counseling?

Yes

No

Other

Please list any medications currently being taken by your patient and its purpose:

1.) (RX Name/Purpose)

2.) (RX Name/Purpose)

3.) (RX Name/Purpose)

4.) (RX Name/Purpose)

5.) (RX Name/Purpose)

ANGER MANAGEMENT / STRESS / SUICIDAL IDEATION

Does your patient have anger management issues?

FOR MILITARY - Out of combat, has your patient ever harmed another person?

FOR NON-MILITARY - Has your patient ever harmed another person?

Does your patient have problems with their ADL’s?

Has your patient ever harmed an animal?

In your opinion, how does your patient respond to the challenge of managing and interacting with their service animal?

If they already have a service animal, how do they say they are managing?

Any other comments or notes we should be made aware of as it relates to your patient having the responsibility of a service animal?

Does your patient recognize signs of stress in their service animal?

Yes

No

Please describe your patient's anger management and/or frustration tolerance skills.

Please provide any additional information related to your assessment of your client's suicidal ideation planned or intent, if applicable.

Does your patient have the ability to recognize when they become overwhelmed and will they seek professional help to manage their emotions and improve the handler/service animal relationship?

Yes

No

In your opinion, can your patient provide care and training necessary to properly care for a service animal?

Yes

No

PLEASE RETURN THIS COMPLETED MENTAL HEALTH FORM EITHER BY EMAIL TO PAWS FOR LIFE USA Admin@pawsforlifeusa.org or

Fax: 770-579-8289

PROVIDER Signature - I hereby certify that all information provided is true, to the best of my knowledge.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

PROVIDER SIGN HERE

Your Professional Title

Name of Practice

Address of Practice

Download Client Consent Form

Download Provider Form

Email Your Completed Form