Application Process

ASDA recognizes that demand for autism service dogs is high and availability is limited. Unfortunately due to the demand, ASDA must qualify applicants. ASDA advises families to apply as early as possible. If you know of a person who might qualify for a dog through ASDA but does not have Internet service, most public libraries do provide Internet access.

For screening purposes please read and complete each of the following steps.

STEP ONE: Print out the questionnaire  here, then answer each question with an X that best describes the child. Keep in mind we are not asking about normal age appropriate behavior. 

Does the child—

1. Run away from caregivers?___never ___sometimes___frequently

2. Demonstrate hyperactive behaviors?___never___sometimes___frequently

3. Demonstrate impulsivity?___never___sometimes___frequently

4. Demonstrate aggressive behavior toward others? ___never___sometimes___frequently

5. Experience temper tantrums?___never___sometimes___frequently

6. Experience a very short attention span?___never___sometimes___frequently

7. Experience oversensitivity to sound?___never___sometimes___frequently

8. Experience oversensitivity to being touched?___never ___frequently

9. Experience an exaggerated reaction to light, odors or other stimuli?___never___sometimes___frequently

10. Demonstrate extreme or abnormal moods?___never___sometimes___frequently
    (giggling or weeping for no apparent reason)___never___sometimes___frequently

11. Demonstrate a lack of fear to real dangers (age appropriate)___never___sometimes___frequently

12. Demonstrate self-injurious behavior?___never___sometimes___frequently

13. Experience difficulty in forming peer relationships?___never___sometimes___frequently

14. Experience seizures?____never____sometimes____frequently

15. Delay in development of spoken language?___yes___no

16. Lack the ability for creative, imaginative play?___yes___no

17. Lack the ability to initiate or sustain conversation (age appropriate)?___yes___no

18. Demonstrate impairment in eye-to-eye contact, facial expression, body postures and gestures?___yes___no

19. Demonstrate repetitive use of language or idiosyncratic language?___yes__no

20. Fail to share enjoyment, interests or achievements with others?___yes___no

21. Demonstrate a lack of social or emotional reciprocity?___yes___no

22. Demonstrate frustration/irritability with minimal changes in routine___No___Mild___Moderate
       ___Severe

24. Take medication?____yes____no

25. My child is a ___boy___girl and is___years of age.

STEP TWO:

3.      A 15 minute DVD or standard VHS (no mini-cam casettes) of the child interacting with, or in the presence of a dog. (The dog in the video or DVD may belong to a neighbor, friend or relative)

       STEP THREE:  

             1.      Print, read, sign, and mail with other documents the following agreement:

  I understand and accept the responsibility, financial investment, and care required of owning a (service) dog. All family members will respect the basic needs of the dog for proper diet, shelter, veterinary care, exercise, attention, and rest. If, at any time, I, or members of my immediate family, cannot meet the requirements of proper care, I understand the service dog is to be returned to Autism Service Dogs of America. I further agree to follow ASDA instruction regarding the required reading, training, and the transition and integration process of the service dog into our home.

Signed_________________________________________Date_____________
   Full name of primary child caregiver/ dog handler

Primary caregiver name:______________________________________________
Primary caregiver address:____________________________________________
City__________________________________State________Zip Code________
Phone:____________________________Email:___________________________
Child’s Name______________________________DOB:____________________

STEP FOUR:

1.      Mail the printed application form & all documents along with a $30 application fee to:

            2. Enclose a 9x4 sized #10, self-addressed & stamped envelope

STEP FIVE:

ASDA will review and evaluate each applicant’s qualification and need, and if accepted into the ASDA    program, the applicant will be contacted within 2 weeks and sent a stage 2  ASDA application form.

STEP SIX:  Click on Fundraising