Personal History Form

MA DDS Partnership Application

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MA DEPARTMENT OF DISABILITY SERVICES PARTNERSHIP PROGRAM

Preferred pronouns:

First Name:

Last Name:

Home Phone:

Cell Phone:

Email:

Work Phone:

Address:

City:

State:

Zip:

Marital Status:

Sex:

Date of Birth:

Current Age:

Are you seeking a dog for yourself?

If not, who are you applying for & what is your relationship to them?

Which of these apply?

Military:

If you are employed, what is your position?

Describe your daily schedule & environment:

If a student, will the dog attend school?

Please provide more info if unsure:

Describe the nature & history of your disability/disabilities (include cause, if applicable/possible):

Will you be able to have a provider (therapist, psychiatrist, GP, etc.) complete our medical history form as required?

Will you be able to provide a letter of support from a friend or relative, if accepted?

Emergency Contact:

What kind of residence do you live in:

If other, please describe:

Do you:

How long have you resided in your current space?

Do you have a yard?

If yes, is it:

Is it:

Do you currently own any dog(s)?

If so, what breed, age & sex?

Do you currently own other animals?

If so, what kind & how old?

Have they been exposed to dogs?

Are they comfortable with dogs?

Do you live in a therapeutic/support/specialized residential facility? If so, what facility?

Tell us what breed(s) of dogs you would like your service dog to be, if possible, and why. (Skip if you have a dog already)

1st Choice:

Why:

2nd Choice:

Why:

3rd Choice:

Why:

Do you have any dog training experience? (not required)

If so, roughly how much?

If you have experience, where did you learn, what methods did you use, and what tasks/behaviors did you learn to train?

Have you/the candidate been convicted of a misdemeanor, felony njp or court-martial?

If so, explain in an attachment.

In your own words, explain how a service dog will improve your/the candidate's life & what service tasks you/they would benefit from.

What led you to the point of seeking a service dog? How did you learn about them?

Do you take medication?

If so, please list all medications, dosages, frequency of use & intended benefit(s).

It is important for us to understand your diagnostic and treatment history. Please use the space below to provide us with a chronological timeline of what diagnosis (or diagnoses) you have been given (even if they have since changed) and all treatment(s) you have received, such as therapy, medication, surgical or other such treatments. Please include all diagnoses, including psychiatric, physical, learning and any other types of diagnoses. Please also include the names of the facilities for any hospitalizations or residential treatments and any/all types of other therapeutic treatments/modalities you have received. Please also briefly describe the symptoms that led to diagnosis and/or treatments. This information will be discussed in greater detail during your interview, but having a general framework or summary to start will help us in the interview process. Feel free to attach/submit additional sheets if required or to submit and file attachment instead, if that is easier. (Acceptable files include a typed PDF, Word Doc, a link to a Google Doc - link should be pasted below.) Thank you for your candor.

My household activity level is:

I would like a dog whose activity level is:

How many children are in your household? (please provide age, sex & any relevant info):

Will you need a dog that is hypo-allergenic?

Have you ever had a seizure(s)?

Do you have seizures regurlarly?

If so, how often?

Do you get auras?

If so, please describe:

BY SIGNING THIS APPLICATION, I HEREBY AGREE TO THE FOLLOWING:

Failure to disclose any primary or secondary diagnoses or intentionally misrepresenting any information when applying or enrolled will result in the forfeiture of any and all payments. Applicants and clients must notify Diggity Dogs of new or altered diagnoses within thirty days of being made aware of them.

Name (print full name):

Date:

Signature:

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Personal History Form

BY SIGNING THIS APPLICATION, I HEREBY AGREE TO THE FOLLOWING:

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