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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,

Date of Birth
Month
Day
Year

Paws For Life USA for a Service dog. They have completed the attached Consent Form found at the bottom of this letter which authorizes you to share information in regards to their PTSD in relation to our service dog program. In order to consider their application can you please provide us with the information requested in the Consent Form. All of the Veterans in our Paws For Life USA program must provide us with written information confirming the diagnosis of Post Traumatic Stress Disorder from a psychiatrist or psychologist qualified to make the diagnosis.

Date of PTSD Diagnosis:
Month
Day
Year

The following is to be completed by the Patients Mental Health Provider (Psychotherapist, MHY Nurse, Registered Social Worker, VA or other qualified professional with experience in PTSD). Providing us with information will help us to “Custom” our support to the Veteran and increase our understanding of the specific disabilities that they have. Our program is challenging for some Veterans, 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 dog. 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 dog 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 strides for a successful partnership with our dog placements. Therefore, we ask that you complete this report. 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 Web Site: https://www.PawsForLifeUSA.org Like us on Facebook: https://www.facebook.com/pawsforlifeusa

MENTAL HEALTH REPORT

Please indicate any disorders experience by your patient:

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

PLEASE RETURN THIS COMPLETED MENTAL HEALTH FORM EITHER BY EMAIL TO PAWS FOR LIFE USA Admin@pawsforlifeusa.org or Fax 770-579-8289

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