Applicant Eligibility Survey (updated 20240819)

Applicant Eligibility Survey

Please be aware that we are not currently taking eligibility surveys for mobility dogs. We will remove this notice when we are able to take them again.

The first step in the application process is determination of your basic eligibility for our program. If you meet the basic eligibility requirements, you will be sent a complete application package and detailed instructions for completing the application.

Please be aware that we are required to collect certain information from participants as part of our eligibility assessment process. This is due to the requirements of a grant that helps fund our program, which mandates that we gather specific data to ensure compliance with their guidelines. The information collected will be used solely for the purposes of determining eligibility and reporting to our grant providers. Your privacy is important to us, and all responses will be kept confidential in accordance with our privacy policy.

If you do not live within 50 miles or approximately one hour’s travel time of Hero Dogs (zip code 20833), do NOT complete this form (see mandatory eligibility requirements).

First Name *

Middle Name

Last Name *

E-mail *

Age *

Address 1 *

Address 2

City *

County *

State *

Zip *

Phone *

Do you own or rent your home? *

How long have you lived at your current address? *

Do you plan to move within the next 24 months? *

No

Yes

If yes, give the city and state to which you plan to move:

Physical/medical condition *

Impaired vision

Hearing

Mobility/balance

Traumatic Brain Injury (TBI)

Other

If other, please specify:

Mental health conditions *

Anxiety

Depression

Panic attacks

PTSD

Social phobia

Suicidal ideation

Other

Training sessions are held at our headquarters in Brookeville, MD, as well as at various locations in the community. What transportation will you use to get to and from training sessions? *

Are you interested in applying for a: *

Service Dog

Skilled Home Companion Dog (no public access)

Please indicate your affiliation(s): *

Veteran of U.S. Uniformed Services

Other

First-responder

Military or first-responder immediate family

Are you released from active duty, or will you be released within the next three months? (You must also be free of any reserve obligation time – see DD214 Block 6) *

No

Yes

Are you currently enlisted/commissioned in the Reserves or National Guard (IRR, Title 32, Title 10, SAD)? *

No

Yes

Have you had a service dog before?

If yes, who trained the dog?

Do you currently have pets? Please specify type, gender, and age of each pet (ex. dog, Labrador, female, 3 years and 2 months). Include all species (dogs, cats, birds, reptiles, rodents, other).

Please select all the ways you feel a dog could help you: *

Physical disability

Balance or mobility

Hearing loss

PTSD or psychiatric disability

Other

If you selected "Balance or mobility," "PTSD or psychiatric disability," or "Other" above, please briefly describe your needs:

Are you currently under the care of a licensed mental health therapist, social worker, psychologist, or counselor? Select all that apply: *

Medication monitoring

Individual psychotherapy

Group counseling

Not currently receiving mental health services

If yes, how long have you been under the care of a licensed mental health therapist, social worker, psychologist, or counselor (years and months)?

If yes, how many hours of counseling/therapy have you had over the past year?

Are you currently under the care of a psychiatrist? *

If yes, how many times have you seen your psychiatrist in the past year?

Do you have prior drug, alcohol, or other substance use disorder? *

No

Yes

How long have you maintained sobriety? If you answered "no" to the previous question, please write "N/A." *

Have you been in an IOP, Residential, Inpatient, or Rehabilitation Program for substance use or mental health treatment in the past year? *

No

Yes

What dates? If none, please write "N/A." *

How did you hear about Hero Dogs? *

Please scan and email a copy of your most recent DD Form 214 (Member - 4 copy) to applicant@hero-dogs.org. If you are a first responder, we will contact you to provide verification of service eligibility.