Inquire About a Dog

Screening Questionnaire

What is your name? What is your phone number? What is an email we could reach you at?

Who is seeking a service dog? (PWP does not provide service dogs to children under the age of 8)Myself (must be at least 18 years old) My child My spouse My parent Other

How old is the person needing assistance?

PWP currently only places service dogs within a 35 mile radius of Louisville, KY. Do you live in our area?Yes No Other

PwP does not place signal (hearing) dogs, medical alert (such as diabetic) dogs or guide (seeing) dogs.I acknowledge

PwP does not place dogs for alert such as a seizure, but our dogs are trained for response.I acknowledge

PwP does not place psychiatric service dogs or emotional support dogs.I acknowledge

Disabilities

One of PWP’s focus is on people with disabilities that affect their mobility. Do you fall into this category? If so, please explain. Another one of PWP’s focus is on people with high functioning autism (must be verbal). Do you fall into this category? If so, please explain. Do you have any diagnoses that have required a psychiatric or psychological evaluation? If so, please explain.

Are you a military veteran?Yes No

What mobility devices do you use?Walker Cane Wheelchair Crutches None Other

Do you feel that a service dog would improve your quality of life in a way that medication and/or medical intervention can’t?Yes No Maybe

What tasks would you like the dog to perform?

Do you have a history of substance abuse?Yes No

How long have you had your disability?

Are you able to provide daily exercise for the dog?Yes No Maybe

Home/Work Life

Are you able to provide a home for the dog for the working life of the dog (approximately 10 years)?Yes No Maybe

Will you be able to care for the dog for the entire duration of their working life (approximately 10 years)?Yes No Maybe

What are the number of people in your home and their ages?

Do you, or any other people in your home, have dog allergies?Yes No Maybe

Have you owned a dog before?Yes No

If there are children in the home, are they nervous around dogs?Yes No Maybe Not Applicable

Our dogs are primarily Golden Retrievers, Labrador Retrievers, or a mix of the two. Does a dog that size present any concern?Yes No Maybe

Do you own or rent your home?Own my home Rent my home Other

Do you live in a smoke-free home?Yes No

Do you have a fenced in back yard?Yes No

How many and what kind of pets are currently in your home? Do you have any major life events (moving, new job, marriage, kids, etc) planned for the next 2 years? If so, please explain

Are you currently working?Yes No

Are you able to drive?Yes No

Commitments

It can take two or more years to match and place a dog with an applicant. Are you willing to wait that long?Yes No Maybe

There is significant amount of book studying and hands-on learning required to have a PWP dog. This includes multiple weekends and 3-6 months of hands-on training before the dog is in your home for good. Your commitment to learning is critical to the success of this partnership. Are you able to commit to this?Yes No Maybe

The full application cost is $100 and the placement fee is $2500. Are you able to cover this expense?Yes No Maybe

PWP requires major medical insurance, which incrementally increases with the age of your dog. Are you able to cover this expense?Yes No Maybe

PWP provides a high level of nutrition for our dogs and expects this to be maintained once matched. The cost may be higher than what you feed your "pet". Are you able to cover this expense?Yes No Maybe

Public access tests are required yearly. Are you willing to put put in the time and effort to ensure a successful result?Yes No Maybe

Our dogs shed. Are you willing to be matched with a dog that sheds?Yes No Maybe

Our dogs require consistent grooming. Will you able to maintain and afford their routine?Yes No Maybe

Our dogs are trained at Kentucky Correctional Institute for Women (KCIW) during the week, but may require you to visit to aid in training. Are you wiling to submit to a background check?Yes No Maybe