Enquiry Form - K9 Heroes 4 Heroes

First Name

Last Name

Phone Number

Date of Birth

Address

City

Zip Code

State

Are you classified as a Veteran, First Responder, reservist, guard, active duty service member, or active duty service member that is pending separation?

Yes No

Do you have a reliable source of transportation?

Yes No

Do you have a valid driver's license?

Yes No

Current mode of transportation:

Do you currently possess a service-connected disability rating from the Veterans Administration (VA) for Post-Traumatic Stress (PTS), Traumatic Brain Injury (TBI), or Post-Traumatic Stress Disorder with Military Sexual Trauma (MST)?

Yes No

Do you understand that service dogs placed by K9 Heroes 4 Heroes are trained to facilitate social interaction, while mitigating symptoms associated with PTS, TBI, and MST?

Yes No

Have you been actively engaged in mental health treatment for your diagnosis for at least one year?

Yes No

Are you willing to provide a referral from your primary care provider(s)?

Yes No

Are you able to provide at least three references from individuals included within your support system?

Yes No

Do you have an increased desire for independence?

Yes No

Are you willing to develop coping skills to better manage anger and frustration?

Yes No

Are you mentally prepared to engage in an intensive learning program designed to equip Veterans and First Responders with modern K9 Training?

Yes No

To be considered for enrollment, Veterans and First Responders must show a willingness to communicate on a frequent basis and submit requested information in a timely manner. Do you feel that you are able to accomplish this?

Yes No

Do you understand that you may not be guaranteed placement with a trained service dog by inquiring or being approved for program enrollment?

Yes No

Message

Please thoroughly review all of your responses prior to submitting your eligibility form.

k9 Heroes 4 heroes

k9 heroes 4 heroes

k9 heroes
4 heroes

K9 Heroes 4 Heroes Initial Eligibility Survey

K9 Heroes 4 Heroes Initial Eligibility Survey

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