Maine Paws for Veterans, Inc · Psychiatric Service Dog (PSD) Training Program Application

General Information

Name *

First Name

Last Name

Gender

Date of Birth *

(mm/dd/yyyy)

Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

County *

Mobile Phone *

Landline Phone

Email *

Verify Email *

Marital Status *

Name of Significant Other or Support Person

First Name

Last Name

Phone

Email

Verify Email

Military Information

Maine Paws for Veterans requires a copy of your DD214 as part of your application.

Have you ever been diagnosed with PTS?

Was your diagnosis through a private therapist or the VA? *

Do you have a service-connected diagnosis of PTS? *

What is your PTS rating from the VA or do you receive social security compensation? *

What branch did you serve? *

Dates of Service: *

Health Information

As part of the application, Maine Paws for Veterans requires submittal of a Therapist Referral.

Maine Paws for Veterans requires all participants in the PTS Service Dog Training program to be in therapy during the program. Are you currently in Treatment/Therapy/Counseling? *

Do you have any known triggers that you would like to share?

Other than PTS are there any physical or mental health issues and/or limitations we should know about? *

Do you have any other special accommodations for any physical disabilities? If yes, explain.

Psychiatric Service Dog (PSD)

Criteria for Potential Canine Candidates

What is a Service Animal? *

Under the ADA, a service animal is defined as a dog that has been individually trained to do work or perform tasks for an individual with a disability. The task(s) performed by the dog must be directly related to the person's disability. We do require a signed form by a licensed Veterinarian and the canine candidate will need to pass a canine temperament evaluation. Do you have a dog that you would like to train to work or perform tasks that are directly related to your psychiatric disability?

If so, please list breed, age, and gender of your dog.

Breed, age, & gender

Canine suitability requirements *

All potential canine candidates must meet the following requirements- 1. A signed veterinary release 2. Proof of spay/neuter 3. Be at least one year old and not more than 3 years of age 4. Have completed a Puppy Star and CGC course 5. Breed is not on the high-risk breed list, per insurance Please confirm that you understand the canine suitability requirements and that you will provide proof of the items listed above.

Are you interested in Maine Paws for Veterans pairing you with a dog to train as a potential service dog?

If so, these dogs are found to be behaviorally suitable, however, are not fully trained. These dogs are normally adopted from local shelters or rescue organizations.

Program Requirements *

Upon acceptance into the Service Dog training program, you will be required to attend weekly in-person, 2-hour sessions for a total of 26 weeks. You will be expected to log an additional 240 hours of independent training using the methods and tools learned in class in order to complete the course. Part of the training requires classes to be held in places like Home Depot, Petco, or restaurants in order to train the dog how to behave in public situations. Are you willing to make this commitment?

Are you able to financially care for a dog, i.e. food and veterinary service if needed? *

Are you able to exercise a dog, i.e. walking/biking/running? *

Housing Information

If you live in a rental, you will need permission from your landlord to have a service dog in training. Please have your landlord fill out and return the Landlord Release Form.

What type of residence is your home? *

How long have you lived there? *

Please list everyone who lives with you or visits regularly and their age: *

Does your home have a fenced yard, enclosed area or other space for a dog to exercise? *

Please describe your outdoor space:

Do you have any other animals/pets/livestock? *

Please list any other animals/pets/livestock:

Employment Information

Are you working? *

Please describe where and your weekly hours.

Please submit an accommodation letter from your employer permitting you to bring your service dog in training or service dog to work.

Additional Comments

Referral Information

How did you hear about us? *

VA referral, friend, social media, internet search

Maine Paws for Veterans Policies

Service Dog Training Program is provided without cost to participants.
Veterans need to be current Maine residents.
Maine Paws for Veterans' programs are substance-free (other than prescribed medication).
No weapons are permitted on the property or at any training location.
I am aware Maine Paws for Veterans will conduct a criminal background check.

*

Yes, I understand and agree to these policies

Please Read

Please understand that your application will not be processed as completed until the following supporting documents are furnished to Maine Paws for Veterans:
• DD214 • Therapist Referral Letter • Release of Confidentiality/VA 10-5345 form • Veteran/Canine Support Document • Landlord Release (if applicable) • Employer Release (if applicable) • Veterinarian Release

Download Referral Form

Click here to download our Referral Form. Please have your mental health provider fill it out and submit it along with DD214 and supporting documents.