Amazing Tails, Inc.

Frist Name Last Name
Month of birth Day of birth Year of birth
Address 1
Address 2
City , Zip Code
Daytime Phone Number
Evening Phone Number
E-mail address
Referred by
Employment Status: Employed Student Unemployed
Name and Address of Employer or School
Job Description or Area of Study
Describe your disability and age of onset
Describe your prognosis if applicable
Do you use any of the following? (check all that apply) Electric Wheelchair Manual Wheelchair Scooter Crutches Walker Cane Other

What types of basic needs do you perform by yourself? Cook Clean Dress Bathe Other

Do you require the assistance of a family member or aide for basic needs? Yes No
If yes, for how many hours per day and for what needs?
How many people live in your house?
Please give ages and relationships
Do you operate a motor vehicle? Yes No
What types of transportation are available to you?
How would you describe yourself?
What types of activities do you currently enjoy outside the home? Restaurants Movies Shopping Theater Sporting Events Travel Swimming Concerts Other

What types of activities do you enjoy in the home? Reading Crafts Gardening Television Other
How many hours do you spend away from home each day during the week?
How many hours do you spend away from home each day on weekends or days off?
Are you planning any major changes in your life during the next 2 years? (check all that apply) Moving Job Change Going Away to School Getting Married Having Children Other

How do you think your life would be different if you were not disabled?
What activities do you wish you could do?
What are your short-term goals?
What are your long-term goals?
Ask your best friend to use five words to describe you:
What do you do when you are frustrated or angry?
Have you ever owned a dog? Yes No If so, what kind?
Do you still have the dog? Yes No If not, what happened?
Have you ever had a bad experience with a dog? Yes No If so, describe what happened
Are there any breeds that you particularly like or dislike?
What kind of needs do you think a dog has?
How much do you think it costs to feed, groom and vet a dog for one year?
Do you currently own a dog which you would like to have evaluated by us to be trained for your use as a Service Dog? Yes No If yes, please provide breed, sex, age, where you got the dog, how long you have owned it, and any other pertinent information:
Do you have any other pets? Yes No
What do you think a Service Dog can do for you?
How do you think a Service Dog would change your life?
What do you expect from an organization that trains service dogs?
What can the organization expect from you?
Do you have the funds to pay for the training of a service dog? Yes No
Are you willing to raise money to pay for the training of a service dog? Yes No
Are you willing to try to locate a sponsor to pay for the training of a service dog? Yes No

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