Date      

Applicant Name      

Street Address      

City/State/Zip Code    

Home Phone              Work Phone

Cell Phone   Email that you check frequently*

* Please note that our preferred method of communication is by email. Some spam filters may delete emails that come from Circle Tail. If you have not received a response within 5 business days, please email or call us to follow up on your pre-applicant questionnaire.

Age of applicant   

Do you live within 90 miles of Circle Tail or within Ohio, Indiana, or Kentucky?

Description of disability   

How long have you had the disability? 

Is your disability stable?  If not, please describe recent acerbation in your condition.

If you have a psychiatric disability, is it currently controlled with medicine?

Describe at least three tasks you would want your dog to do for you? 

How many people in the house and ages?      

Number and type of pets in the home (Please note, we generally do not place assistance dogs in homes with young or adult dogs. Exceptions may be made for homes with senior dogs.)

Living arrangements (apartment, house with fenced yard, etc.) 

Would you be able to financially support the dog?   

Describe how your dog will receive exercise?  

Are there three family/friends in the community that will agree to provide short-term care for your assistance dog if an emergency occurs?

How will you clean up after the dog?

Are you able to travel to Circle Tail for an initial interview and for the four weekend partnership process?

Are you able to attend three (3) Assistance Dog Club (ADC) of Circle Tail meetings and two (2) ADC meetings within one year of partnership?

Thank you for completing the pre-applicant questionnaire. A Circle Tail Assistance Dog Committee member will contact you within 2 - 3 business days regarding your questionnaire.