AUTISM SERVICE DOG PRE-QUALIFYING QUESTIONNAIRE 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.Child's Name (Individual with Autism)* First Last Age of Applicant*Applicant must be between the ages of 4 and 12Please enter a number from 0 to 99.Applicant's Name (Third-party handler of service dog) First Last Age of Legal Guardian* Email* Does your child have a diagnosis of Autism?* 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 leave your family and travel for a week in order to participate in a classroom/group setting for Team Training?* Yes No It is a requirement that our dogs are always supervised by their handler or safely crated. They are not allowed to have free run of the house or put outside because that gives them an opportunity to practice unwanted behavior which can affect their effectiveness as a service dog. The dogs cannot be crated for any longer than 6 hours, can you meet these requirements?* 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 Does your Child like Dogs?* Yes No Applicant's Home 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone*Legal Guardian's Occupation (Third-party handler of service dog)* Please check off all items that apply. Select All My child is receiving ABA therapy. My child is receiving speech therapy. My child is receiving occupational therapy. My child has repetitive behaviors that need interrupting. My child is non-verbal. My child elopes. My child has physical or mobility limitations. My child has sensory processing challenges. My child requires assistance feeding. My child requires assistance toileting. My child requires assistance dressing. My child has frequent tantrums/meltdowns. My child takes medications. My child uses augmentative devices to communicate. My child is home schooled. My child’s therapies take place in school. My child’s therapies take place outside of the school. None of the above. Other: Please provide detailed information on any items checked, as well as any additional information relating to your child's symptoms.*List all household members. (Include age & relation)*List all pets in household. (Include species, breed & age)*HiddenAdmin and Hidden FieldsHiddenAge of ApplicantPlease provide a number HiddenLegal Guardian's Name (Third-party handler of service dog)
