Successor Service Dog Application

TLCAD recognizes the that the bond our teams have lasts a lifetime, and no dog can ever be replaced. We also recognize our clients needs for a dog may continue once their service dog retires or passes, and TLCAD is here to support you on your journey to obtain a successor service dog.

Please note that TLCAD currently utilizes a Team Training model to place service dogs (to include successor service dogs). Prior to applying for a successor dog, please click here and familiarize yourself with our Team Training process.

Name

First Name

Last Name

Child’s Name (if applicable)

Main Phone

(###)

###

####

Alternate Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Disability Diagnosis

Do you have a caregiver?

Yes

Primary Caregiver’s Name

First Name

Last Name

Primary Caregiver’s Phone

(###)

###

####

Primary Caregiver’s Email

Please list other members of household and their relationship below. *

Does anyone in your household have allergies?

Yes

Please list all pets in the household below. Include their species, breed and age.

Do you have a diagnosis of PTSD?

Yes

If yes, how do your symptoms of PTSD effect you on a day to day basis?

Do you have a TBI?

Yes

If yes, how do your symptoms of TBI effect you on a day to day basis?

Do you have mobility limitations?

Yes

If yes, please describe your mobility limitations and how they effect you on a day to day basis.

Does your child have a diagnosis of autism?

Yes

If yes, please describe how symptoms of autism affect your child on daily basis.

Please list employment status.

Part TIme

Full Time

Unemployed

If you work, please list employer and position.

Are you currently in school/college?

Yes

Please list your typical weekday schedule (e.g., routines, activities, hobbies).

Please indicate the status of your dog. *

Still in service but will retire soon due to age and/or health

Retired and living inside the home

Retired and living outside the home

Deceased

If your dog is deceased, please indicate the date deceased.

YYYY

If your dog is retired or will retire soon, please indicate their health status and any diagnosis or prognosis provided by your veterinarian(s).

If your dog is currently working, please indicate the ideal timeframe for obtaining a successor dog.

Please list what behaviors your current, retired, or past service dog did to assist you.

Please describe the assistance you expect from a successor service dog.

Is there any additional information you would like to include?

I have read, understand, and can participate in TLCAD’s Team Training process to be placed with a successor dog.

Per Assistance Dogs International Standards, TLCAD service dog recipients are eligible to be placed with the next appropriate service dog that has the strengths, skills, and temperament to meet their needs. Current clients must be re-screened for placement and participate in TLCAD’s Team Training process in order to be eligible to be placed with a successor service dog.

Yes

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Successor Service Dog Form

Successor Service Dog Application

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