Client Application – Bodhi battalion

We will contact you to schedule an interview after your application has been reviewed. All information must be received to continue with the interview process.

$25 Application Fee
Part A - Client Application
Part B – Background Check
Part C ◉ Two Letters of Recommendation ◉ For Non-Active Military: A Copy of Your DD214 Form
Part D – Medical Form
A 750–1250-word essay detailing why you are seeking a service dog and how you believe a service dog will benefit your life

The contents of your application and all personal health information are confidential. Applications are maintained through a HIPPA secure electronic system administered by the Bodhi Battalion.

Part A - Client Application, completed by the client, two letters of recommendation, and a $25.00 application fee.

Part B - Medical Form, completed by your physician or therapist, describing your disability.

APPLICATION PART A

Date

Name

First

Last

Date of Birth

Age

Height

Weight

Sex

Address

Address Line 1

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Name of Nearest Relative

Relationship

Address of Relative

Relative's Phone Number

This application must be IN THE WORDS OF THE PERSON WHO WILL USE THE DOG. If writing is difficult for you, provide the name and relationship of the person transcribing your words.

Name

Relationship

How did you learn about Bodhi Battalion?

Please review the application instructions before completing this form. Your application will be reviewed, and an interview scheduled when all information has been received.

Military Personnel Only:

Do you have a military affiliation?

What branch?

Are you active or retired?

For non-active military clients, please attach a copy of your DD214 form to this application

Please select from the following list the type of dog that would be best for your current situation:

Service Dog ◉ A service dog is trained to perform a minimum of three custom tasks for a person with a disability. When properly trained, the dog is granted full public access. A service dog can be placed with a client that is at least 16 years of age or older and can handle the dog in public without assistance.
Service Dog - 3rd Party ◉ A 3rd party service dog is trained to perform a minimum of three custom tasks for a person with a disability. The dog is granted full public access providing that a parent or guardian is always with the client when in public. Third-party service dogs are available to clients under the age of 16 or unable to handle a dog in public without assistance from a guardian or caregiver.
Skilled Companion Dog ◉ A skilled companion dog is trained in basic obedience skills and some custom tasks to assist a client with a disability. The dog is not granted public access and is trained to help the client only in the home.

Disability and Diagnoses

What is your disability?

Most Bodhi Battalion dogs assist people with primary mobility impairment, such as multiple sclerosis, muscular dystrophy, amputation, stroke, or traumatic brain or spinal cord injury. Our dogs also serve clients with PTSD.

Bodhi Battalion does not train dogs to assist individuals with seizure disorders, blood sugar disorders or those with significant vision or hearing impairment.

Do you have any other diagnoses, including mental health diagnoses?

How long have you had this disability?

If the disability was caused by injury, what progress has been made post-injury?

Which do you use most often?

Do you drive?

Describe your physical strengths and abilities. (Circle one number for each limb.)

LEFT

No Use ->->-> Full Use

Hand Strength

Selected Value: 1

Dexterity

Selected Value: 1

Arm Strength

Selected Value: 1

Upper Body Strength

Selected Value: 1

Leg Strength

Selected Value: 1

Leg Control

Selected Value: 1

RIGHT

No Use ->->-> Full Use

Hand Strength

Selected Value: 1

Dexterity

Selected Value: 1

Arm Strength

Selected Value: 1

Upper Body Strength

Selected Value: 1

Leg Strength

Selected Value: 1

Leg Control

Selected Value: 1

Have you fallen?

How often do you fall?

Please describe your fall and if you can catch yourself:

Please rate: (On a scale of 1=Poor – to – 10=Normal)

Your Speech?

Selected Value: 1

Easily understood

Selected Value: 1

Tone variation

Selected Value: 1

Volume

Selected Value: 1

Describe the use of attendants, including how many and how often? (Daily, weekly?)

Please describe your limitations – mobility, physical strength, endurance, reaction speed, balance, vision, speech difficulties, heat, cold or pain sensitivity, and anything that might help us understand your needs.

What work, school or rehabilitation program(s) have you completed?

What is your current work or school schedule?

List the people living in your home, including their ages and their relationship to you.

Do any other members of your household have a physical or mental disability?

If so, how are they disabled, and what are their limitations?

Please describe your home and yard.

Is your yard fenced?

If yes, how high is your fence?

If your yard is not fenced if your fence is too short or needs repair, will you be able to put up a securely fenced area before you receive your dog?

What pets do you have now? Describe type and age.

Veterinarian’s name and phone number:

If you have a dog now, would you be willing to give up your present dog if it cannot get along with a Bodhi Battalion dog?

If your present dog is not well-mannered, are you willing to train your dog before you receive your Bodhi Battalion dog?

What dogs have you had before? Describe what breed and your age at the time.

Have you ever re-homed a pet? If so, what was the reason?

On a daily basis, how will you handle walking, cleaning up after, feeding, medicating, exercising, grooming, and medical care for your Bodhi Battalion dog?

How will you handle the care of your Bodhi Battalion dog if you are hospitalized?

Will it be difficult for you to do the following?

Limit your calendar for the 30-day bonding period.

Attend an approved Obedience Class?

Please explain any Yes answer

Living with a Bodhi Battalion Dog, do you agree to the following terms and conditions:

1) There is a reasonable expectation that your medical situation will allow you to use and benefit from your dog’s skills for 8 to 10 years.

2) A “Bodhi Battalion Dog” is not a family pet – they have a specific function in their partner’s life and minimal interaction with others.

3) You and your dog are ambassadors for Bodhi Battalion, as well as for the entire assistance dog industry (guide, hearing, and service dogs), and you will be expected to maintain your dog’s appearance and manners, and behavior as well as your handling skills.

4) A Bodhi Battalion dog will not be allowed off-leash except in a secure area. Exercise and elimination must be done on a leash or in a fenced yard or dog run.

5) You assume full responsibility as caretaker of your Bodhi Battalion dog, in charge of their safety, health, and welfare. Their needs include:

Medical care – all care prescribed by your veterinarian and routine annual care as directed by Bodhi Battalion.

Nutritional care – including the use of good quality dog food and maintaining your dog’s proper weight.

Daily exercise and play

6) You assume full responsibility for maintaining appropriate training and behavior, annually updating your public access certification or Canine Good Citizen certification as applicable.

7) You will maintain identification for public access, if applicable.

8) That you assume full responsibility for cleaning up after your dog eliminates in public and for the cost of repairing any damage caused by your dog.

By signing below, you agree to these conditions. Please explain any “no” answers and attach additional sheets if needed

Signature of Applicant

Date

Finance Worksheet – Planning for Your Dog

The questions below are meant for you to think critically about the financial impact a a service dog may have on your life. While Bodhi Battalion does not charge our clients for a service dog, we do require that our clients assume the financial responsibility that goes along with caring for the dog, including but not limited to food, veterinary care, treats, toys, beds, emergency costs, and possibly boarding.

• We estimate that the cost of a service dog is approximately $2000 per year. This is a basic estimate based on the cost of food, a yearly checkup for your dog, vaccinations, and a small stipend for unexpected veterinary occurrences.

Do you feel comfortable taking this cost on?

Although $2000 per year is a good place to begin budgeting, unexpected veterinary costs can happen. Please read the following scenario and explain how you would respond.

You have taken your dog to a dog park for some exercise and play. Your dog starts playing with another dog, and they are tumbling around the yard. Later, when you get home, your dog appears to be limping and cannot put any weight on one of his legs. You take your dog to the vet and find out that he has torn a ligament and needs TPLO surgery – not an uncommon occurrence in large dogs. The cost will be anywhere from $2,980- $3,180 for surgery and post-operative expenses. Provide your answer below:

• What is the limit to the amount of money you could spend on veterinary care?

• How much money is too much to spend on these types of costs?

• Would you consider euthanasia due to high medical costs?

• Have you ever, in the past, had to euthanize a pet due to the cost of medical care? If yes, please describe the situation:

Bodhi Battalion Client Application (continued)

Source of Income

Professional
Self-Employed
Government Benefits
Other

If you are employed, please describe your work:

Number of years in current place of work:

Monthly Income:

Please estimate the following expenses on a Monthly basis where applicable:

Rent/Mortgage

Utilities

Medical Care

Car Payments

Credit Card Payments

Expenses for other animals in your home

Please take a moment to think critically about your monthly expenses and budget. Using this information and your current income, please fill out the following “Finance Worksheet” using your best estimates to map out what you can afford on a MONTHLY basis for your dog.

Dog food:

(You can estimate that your dog will eat between 2-4 cups of dog food per day, depending on the size of the dog).

Treats:

Grooming:

(this cost will vary dramatically based on the type of dog you get. If you have specifically requested a poodle or poodle mix, this cost will be higher)

Savings towards veterinary expenses:

Bodhi Battalion Client Application

Application Section B – Background Check

For us to process your application and schedule an interview, we will need a completed background check. Please complete the information below. We will run the background check for you and destroy the sheet containing your SSN. Please type or print clearly.

Name

First

Middle

Last

Gender

Social Security Number

Date of Birth

Marital Status

Country

Address

Address Line 1

City

State

Zip Code

Date Moved In

Have you ever been convicted of a crime? A conviction will not necessarily bar you from receiving a dog.

If yes, please describe:

Bodhi Battalion Client Application (continued)

Letters of Recommendation

Please list the name and contact information of two people who will provide letters of recommendation for you. We will need a physical letter from both people, either included with the application or sent separately to Bodhi Battalion.

1) Personal (not a relative)
2) Professional (therapist, doctor).

Please send letters of recommendation at email: joanna@bodhibattalion.org or info@bodhibattalion.org

Please download this form and have it completed by your provider.

Download Your Medical Form