VETERAN SERVICE DOG PRE-QUALIFYING QUESTIONNAIRE Please watch the Veteran Service Dog Education Video below before starting the application process. Obtaining an assistance dog is a major lifestyle change and commitment. To determine eligibility for our program, please submit the Pre-Qualification Questionnaire below. Completion of this form does not guarantee you will be matched with a service dog. Prior to beginning the application process, please be sure to determine if a TLC dog is right for you by reviewing the requirements here.Name* First Last Email* Are you a veteran with a diagnosis of a mobility limiting disability, Post-Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI), or Military Sexual Trauma (MST)? *Please note, a copy of your DD 214 will be required to confirm separation from the military.* Yes No Are you able to afford the costs of caring for a service dog to include food, equipment, supplies and veterinary care for the lifetime of the service dog, an average of $50-$200/month?* Yes No Are you able to travel without your family and cope with the stresses of being in a new environment while participating in a classroom/group setting for a week?* Yes No TLC uses only positive reinforcement training methods. A service dog’s training must be maintained by their recipient. If selected, are you willing to use only positive reinforcement training methods and actively participate in the dog’s ongoing training, annual assessments and health checks for the working life of the dog?* Yes No Address* Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone*Please state your diagnosis and describe your symptoms. If you have PTSD, please list all triggers, reactions to triggers, recovery time & frequency. If you have a mobility limiting disability, please list all assistive devices/equipment used.*Are you currently receiving treatment for PTSD?* Yes No Do you have a caregiver?* Yes No Please list all members of your household and include ages & relation.*Do you have other pets in the home?* Yes No List all pets, include species, breed & age.*Do you plan on taking the dog to work?* Yes No Not Employed Please provide information about your employment status (full or part time). Include occupation and employer.*How did you hear about us?*
