Service Dog Intake Form

Please take the time to fill out this form to the best of your ability. Answering questions honestly and with detail helps Roam assess the best services and create a training plan for you and your dog.

Client Information

First name

Last name

Pronouns

She/Her

He/Him

They/Them

Other

Phone

Address

Emergency Contact

Your emergency contact may be your partner, friend, or family member. If an emergency occurs involving you or your dog during a daytime service (eg, training, hiking, walking, etc), your emergency contact may be called in order to assist, make medical or logistical decisions, and/or pick up your dog.

First Name

Last Name

Phone

Address

Disability Information

What disability/disabilities or medical condition(s) are you seeking a service dog to mitigate?

What specific challenges are you hoping a service dog will help you manage?

What tasks are you hoping your dog will perform to mitigate your disability? If you are not sure what tasks might be helpful for you, say “not sure”.

What other treatments and/or supports do you use regularly to help with your disability? (e.g., daily medication, continuous glucose monitor, Apple Watch to track heart rate, mobility devices, support person, injections, etc)

Are there any upcoming life changes (moving, school, employment, travel, etc.) that may affect your training goals or service dog needs?

I understand that not all dogs are suitable for service work. If I choose to train with Roam, I understand that my dog may be given a break from training and/or washed (removed) from training at any point if deemed necessary by Roam.

Training Logistics

If you have a timeframe or date you wish to start services, please specify below

Service dog training is a huge time and energy commitment. It requires regular training in various public locations, daily homework, and handler consistency. Are you prepared to spend 1-2 hours a day training for the duration of your dog’s training?

Yes

Are there any aspects of your disability that may affect your ability to consistently train, exercise, or care for a dog daily? If yes, please explain any support systems/accommodations you have in place to ensure continuous care, exercise, and training.

Are there any spaces that you find difficult to navigate due to your disability? (e.g., severe anxiety in large crowds, public transit can be inaccessible due to the lack of dependable elevators, etc.).

Are there any accommodations you need to participate in training sessions?

Do you currently have a prospect (a dog or puppy you want to train as your service dog) or a service dog in training (SDIT)?

Yes, I have a prospect or SDIT

No, I do not have a prospect or SDIT