Veteran's Service Dog Program Application

  • SERVICE DOG PROGRAM APPLICATION

    • SECTION-APPLICATION INSTRUCTIONS 

    • To be eligible to enter This Able Veteran’s service dog program you must be a U.S. veteran:

      • Whose injuries took place during military service (stateside or deployed).
      • Or post-service work as a first responder or healthcare worker
      • In treatment with a licensed therapist (preferred) or currently enrolled with the V.A. Behavioral Health Program
      • Willing to submit to a criminal background check.
      • Committed to taking the steps necessary to take charge of your life and your future.
      • Have the resources/support system to meet the needs of a service dog.

      Note: A digital copy of your DD Form 214 will be required to complete this application.  Please have this available.

      The application is divided into multiple sections and involves input from the Veteran's therapist as well as from a member of the Veteran's family.

      Please note that sending in the application is only the first step in the process. The application will be reviewed upon receipt; any additional  information needed will be requested from the veteran, their medical professional or their family member. Once the application is complete it must be reviewed by the Application Committee for tentative approval. The veteran will be notified by a representative of This Able Veteran as to the status of the application.

      Once a service dog is matched to the veteran, the veteran must be able to travel to Illinois and attend the entire training session required by This Able Veteran. If an applicant is unable or unwilling to attend the entire training session, they will not receive a service dog. 

      Do not assume that answering a question in a particular way will automatically disqualify the veteran from the program. We are not looking for the "right" answer. We want honest answers. This will assist us in helping the veteran.

      Questions regarding this process may be emailed to: servicedog@thisableveteran.org. No confidential information should be sent via email. Send us a note, including phone number, state that there are questions about the application and we will call the veteran.

      Please complete the below online appliation.  Upon submission, an email notification will be sent to the designate therapist & family member to complete their portion of this application.

    • SECTION-CONTACTS INFO 

    • CONTACT INFORMATION

    • Why are you asking me for this information?

      After the you, the applicant completes your portion of the application, the therapist & family member that you designate below will be notified via email and asked to complete their portion of this application through our HIPAA compliant program.

      The information collected in this section is used solely for the use of notification and their name's and contact information will not be disclosed to any other parties.

    • SECTION-VETERAN INFO 

    • GENERAL INFORMATION

      (To Be Completed By Applicant)

    • Please note: Application must be completed by the veteran or answered under the direction of the veteran. If completed by someone other than the veteran please identify the person completing the application and explain why the veteran is unable to complete the application on their own.

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    • Date Of Birth:*
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    • Gender:*
    • Marital Status:*

    • Are You Currently Employed?*
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    • Emergency Contact

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    • MILITARY INFORMATION

    • What Is Your Military Status?*
    • Honorable:*
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    • HOUSING INFORMATION

    • With Whom Do You Live? (check all that apply)*

    • Do You Have A Strong Support System?*
    • What Type of Residence Is Your Home?*

    • Does Your Home Have A Fenced Yard, Enclosed Area Or Other Space For a Dog To Exercise?*
    • Do You Own Any Pets?*

    • CIVIL/CRIMINAL CHARGES

    • By completing this section, you affirm that you understand past convictions of any of the following crimes will make an individual unsuitable for a service dog: Animal abuse, child abuse, domestic abuse, sexual abuse, and violent crimes.*
    • Have You Ever Had, Or Do You Have, Pending Criminal Charges?*
    • Have You Served, or Are You Currently Serving, Parole or Probation?*
    • Have You Ever Been Charged With Driving Under The Influence?*
    • Have You Ever Been Charged With Domestic Violence?*
    • Have You Ever Been Charged With Animal Cruelty?*

    • OWNING A DOG

    • Have You Ever Owned An Animal, Specifically A Dog?*
    • Do You Reside With, Or Visit Children Regularly Or Do Children Regularly Visit You?*
    • How Frequently?

    • PERSONAL INFORMATION

    • These questions will help us choose and train the best dog for your personality and emotional needs. Please answer them, and feel free to add any extra comments that might help us understand how you respond in different situations.

    • Are You Able To React Calmly In A Crisis?*
    • Are You Able To Feel & Express Fear?*
    • Are You Able To Feel & Express Sorrow?*
    • Are You Able To Feel & Express Love?*
    • Are You Able To Feel & Express Anger?*
    • Are You Able To Feel and Express Joy?*
    • When Challenged, Do You Feel Able To Stand Your Ground?*
    • Are You Willing To Learn New Concepts, Even If They Are Contrary To Your Current Beliefs?*
    • Are You Able & Willing To Assume Full Responsibility For Your Behavior?*
    • Are You Able to Control Your Emotions / Can You Recognize When You Are Emotionally Overwhelmed & Take Positive Steps To Gain Control?*
    • Are You An Emotionally Sensitive Person?*
    • Are You Willing To Accept Constructive Criticism?*
    • Are You Able To Laugh At Yourself?*
    • Are You Sensitive To Being Embarrassed?*
    • Are You A Shy Person?*
    • Are You Able To Empathize (Understand & Relate To With Other People)?*
    • Are You Able To Provide Proper Nutrition, Cleanliness, Warmth, Grooming, Bathing & Exercise As Well As Ensure Timely & Proper Care For The Dog?*
    • Do You Have The Capacity To Meet The Service Dog's Social & Emotional Needs Throughout The Dog's Life?*
    • Do You Have The Ability, Motivation & Resources To Accept Responsibility For Using The Dog Appropriately?*
    • Can you affirm you understand the costs and have adequate financial resources to care for a dog, including Annual Costs Of Veterinarian Care, Flea & Tick Treatment, Heartworm Medication, Supplies, & Other Medicine As Needed For examples, visit: https://www.akc.org/expert-advice/lifestyle/know-true-cost-owning-dog/ ?*

    • VETERAN ACKNOWLEDGEMENT

    • All participants shall be familiar with, and comply with, the regulations implementing the Americans with Disabilities Act (ADA) for Title II and Title III, dated September 15, 2010 regarding the use of a service dog. ADA guidelines can be found online at www.ada.gov. Failure to do so could result in the loss of your service dog after graduation.

      By signing this application the veteran is granting permission for This Able Veteran staff to communicate with individuals designated in this application as medical or family.

      I have disclosed all information to the best of my knowledge. I understand that failure to disclose, or providing a false response, shall be grounds for automatic disqualification from consideration for, or expulsion from, the program.

      If the applicant is a minor, or under guardianship or conservatorship, or a ward of the court, the parent or duly authorized representative is required to sign below pursuant to state and federal law.

    • Signature Date:*
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      If the applicant is a minor, or under guardianship or conservatorship, or a ward of the court, the parent or duly authorized representative is required to sign below pursuant to state and federal law.

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    • Auth Rep Date:
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    • SECTION-PHOTOGRAPHY RELEASE 

    • PHOTOGRAPHY AUTHORIZATION AND RELEASE

    • I consent to being photographed/videoed by This Able Veteran, and/or its designee in connection with the training, promotion, marketing and educational endeavors of This Able Veteran, and/or its designee.

      I understand that such photographs/videos may be published in any print, visual or electronic media, including, but not limited to, marketing materials, brochures, pamphlets, videos, website, social media, medical journals and textbooks, for the purpose of informing the medical profession, service dog training profession and/or the general public about service dog training methods for veterans with disabilities.

      I understand that the photographs may portray features which will make my identity recognizable.

      I understand that I have the right to revoke this authorization in writing at any time, but if I do so it will not have any effect on any actions taken prior to my revocation. If I do not revoke this authorization, it will automatically expire ten years from the date written below. I understand that I may refuse to sign this authorization and such refusal will have no effect on the services I receive from This Able Veteran.

      I release and discharge This Able Veteran and all parties acting under their direction and authority from all rights that I may have in the photographs and from any claim that I may have relating to such use in publications, including any claim for payment in connection with distribution, licensing or publication or reprinting of the photographs.

      I have read this Authorization and Release and have had an opportunity to consult legal counsel with respect to this. By placing my signature below I fully consent to the terms and conditions contained herein. This consent is a voluntary contribution in the interest of public education and I certify that I have read the above Authorization and Release and fully understand its terms.

    • DATE (Photography Authorization):*
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    • DATE (Photography Authorization):*
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    • SECTION - HEATLH DISCLOSURE 

    • One of your patients has applied to This Able Veteran (TAV) for inclusion into our program and to receive a service dog. To find out more information on our program, I invite you to review our website (www.thisableveteran.org).

      TAV has been assisting veterans diagnosed with PTSD since 2011. Our program is unique in our approach. We combine online workshops prior to and post our 3-week in-house session. Veterans who are selected for our program are brought to southern IL for an intensive onsite training experience where they not only learn the benefits of a service dog, how to work with and care for their new partner, but also are provided with life skills to cope with their trauma, are exposed to alternative therapies (acupuncture, etc.), and are taught how to approach life from a place of learning and healing.

      Our application/selection process includes receiving information from the veteran, a family member, and their mental health professionals. Below you will find the patient's completed Authorization To Disclose Health Information form.

      If you have any questions regarding your client’s application, please contact us at 618-964-1162.

      To complete your portion, scroll past the authorization form and complete the Medical Information section.

    • AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

    • I, , hereby authorize to furnish the following medical information to: This Able Veteran, 1714 S. Wolf Creek Road, Carbondale, IL 62902.

    • Purpose of Disclosure: This Able Veteran trains PTSD service dogs to identify early signs and symptoms related to emotional states that are occurring and provide notice to the veteran. Detailed information about symptoms and unwanted behaviors allows for more precise and effective training. In addition to providing highly trained service dogs to veterans suffering from PTSD, This Able Veteran conducts an intensive peer-supported, psychoeducational program that teaches human resilience skills.This program supplements the veteran’s ongoing treatment provided by his/her medical/clinical team. In order for This Able Veteran to design individualized programming we need detailed information about the veteran’s ongoing treatment programs and his/her responses to that treatment.

    • Date Of Birth:*
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    • Please provide the following information and send it to.  If you prefer, you can mail to: This Able Veteran, ATTN: Applications, 1714 South Wolf Creek Rd, Carbondale, IL 62902:

      1. Admitting problem (may include intake summary)
      2. Psychiatric, psychological and social histories
      3. Physical exam and history
      4. Current treatment plan
      5. List of all current medications including dosages
      6. Progress notes covering the last six months of service
      7. Discharge summary (if client has been discharged from your treatment service)
      8. Current diagnosis (or diagnosis at discharge)
      9. Suicide or other risk assessments
      10. Special observation or support needs related to safety or suicide prevention
      11. Any medical information that may impact the verteran's ability to meet the needs of the service dog.

      By initialing below, I specifically authorize the release of my mental health, developmental disabilities, alcohol/ substance abuse and HIV/AIDS information:

    • I understand that:

      • I have the right to inspect and receive copies of information disclosed.
      • I have the right to revoke this consent at any time.
      • Revoking this consent shall have no effect on disclosures made before the revocation of consent.
      • Any revocation of consent must be submitted in writing to the health care provider and signed by the person who gave the consent.
      • If I refuse to consent to this disclosure of information, This Able Veteran will be unable to enroll me into its program due to lack of medical information.

      I agree that a photocopy of this authorization is as valid as the original.

    • Signature Date:*
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    • Authorization Expires:*
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    • SERVICE DOG PROGRAM APPLICATION
      MEDICAL OR MENTAL HEALTH PROVIDER RELEASE

      (Completed By Applicant)

    • Please release the requested medical information regarding my condition to This Able Veteran. The information will be used to help the organization determine my eligibility to obtain a service dog.

    • Patient Signature Date:*
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    • SECTION-MEDICAL INFO 

    • MEDICAL OR MENTAL HEALTH PROVIDER CONTACT INFORMATION

      (Completed by treating clinician)
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    • Requested Medical Information

    • Date Of Diagnosis:*
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    • Please rate each of the following using these number descriptions:
      0 = non-applicable 1 = mild 2 = moderate 3 = severe

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    • PSYCHOLOGICAL / BEHAVIORAL DESCRIPTIONS

    • Please rate each of the following using these number descriptions:
      0 = non-applicable 1 = mild 2 = moderate 3 = severe

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    • Is Patient Currently Participating In Treatment?*
    • Has the patient received treatment in the past?*
    • Has the patient participated in an in-patient or out-patient mental health program?*
    • Did Patient Comply With Treatment Recommendations?*

    • History Of Psychiatric, Psychological/Behavioral Hospitalizations:

      (Include Dates)
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    • ADDITIONAL MEDICAL CONDITIONS: (Check All That Apply)*

    • ASSISTIVE DEVICES: (Check All That Apply)*

    • Functional Independence Measure

    • Please rate (write number on the line in next to the activity) the Functional Independence Measure (FIM) levels for the following motor activities based on this scale:

      NO HELPER HELPER-MODIFIED INDEPENDENCE HELPER-COMPLETE DEPENDENCE
      7 - Complete independence
      (timely, safely)      		 5 - Supervision 1 - Total assistance
      (can perform 0% of activity)
      6 - Modified independence (device) 4 - Minimal assistance
      (can perform 75% of activity)      		 2 - Maximal assistance
      (can perform 25% of activity)
        3 - Moderate assistance
      (can perform 50% of activity)      		  
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    • Would You Recommend This Individual For A Service Dog?*
    • Do You Think This Able Veteran Would Benefit From A Consultation With You To Help Us Facilitate Placement Of A Service Dog For This Patient?*
    • Do You Think This Individual Has The Ability To Care For A Dog*
    • Do You Think This Patient Requires Special Supervision Or Other Supports Necessary To Prevent Him/Her From Self-Harm Or From Harming Others?*
    • Do You Believe That This Patient Has Sufficient Self-Control To Deal Appropriately With Interpersonal Conflicts, Disappointments And Decisions That Do Not Go His/Her Way?*
    • I Believe this patient is capable of caring for a service dog.*
    • I Believe this patient is capable of maintaining the training of a service dog once the initial handler training is completed.*
    • I Believe this patient is capable of traveling to participate in a 3 week onsite handler training, .*
    • Is There Anything You Would Like To Talk To Us Personally About Concerning This Patient?*
    • Provider Signature Date:*
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    • SECTION-FAMILY QUESTIONNAIRE 

    • FAMILY QUESTIONNAIRE

      (Completed By Parent, Spouse, Significant Other Or Other Family Member
      That Currently Lives With Or Sees The Applicant On A Weekly Basis.)

    • All comments and responses are confidential and will not be shared with the veteran. This form is intended for This Able Veteran’s assessment purposes only. Truthful, honest and full disclosure is extremely important to a proper assessment and potential placement of a service dog.

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    • VETERAN’S MENTAL AND EMOTIONAL STATUS

    • Do You Feel The Veteran Acts In Ways That Are Beyond His/Her Control?*
    • Can The Veteran Learn And Follow Direction To The Degree Necessary To Take Care Of A Service Dog?*
    • Is The Veteran Able To Make Rational Decisions About Protecting Herself/Himself As Well As The Needs And Safety Of Others?*
    • Is Veteran’s Disability Affected By Drug Or Alcohol Use Or Abuse?*
    • Is The Veteran Capable Of Making Rational Decisions?*
    • Does The Veteran Pose A Danger To Herself/Himself Or Others?*
    • Does The Veteran Pose A Danger To Herself/Himself Or Others?*
    • Does The Veteran Exhibit Awareness Of Surroundings?*
    • Is The Veteran Oriented To Time, Place And Person?*
    • Does The Veteran Have An Appropriate Attention Span?*
    • Does The Veteran Have The Ability To Relate Positively With Others?*
    • Can The Veteran Communicate Ideas Clearly?*
    • Can The Veteran Follow, Absorb And Incorporate Step-By-Step Instructions?*
    • Is The Veteran Able To Form Insights, Judgments And Plan A Course Of Action?*

    • FAMILY QUESTIONS

    • Do You Have Any Concerns About The Veteran Obtaining A Service Dog?*
    • Are Any Members Of The Veteran’s Support System Allergic To Dogs, Dog Hair Or Dander?*
    • If you reside with the veteran, Do you affirm it is ok with you to have a service dog in the home.*

    • Would You Like Clarification Or Need To Speak To Us For Additional Information?*
    • Best Method To Contact You?*

    • Thank you for taking the time to complete this questionnaire. If the veteran is accepted, we look forward to working with you as a helpful contributor to their recovery.

    • Date:*
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