PART TWO: DISABILITY INFORMATION
What is (are) your disability(ies)?
At what age did you develop this/these disability(ies)?
How long have you been physically challenged?
What caused your impairments?
In what ways are you limited or challenged by this?
What areas of your life are affected by this?
How do you believe a service dog will benefit you?
What exercises and tasks could a service dog do to enhance your life?
Where and how would a service dog be most useful for you? (Work, home, school).
Describe adaptations you need to make because of your disability(ies) to facilitate your activities
of daily living.
Describe how you think a service dog could be involved in each of the activities you have mentioned
in the previous question.
Do people have difficulty understanding you when you speak?
If Yes: Do you use a computer voice assistive device or communication board?
Please list all equipment used to manage your disability:
Do you need help with participating in your normal activities of dailiy living, if so, what
type of help, and who helps you?
Is there any other information that you think may help with the selection of the
right dog for you: