Request an Autism Dog

General Information

The Child (the candidate)

First Name *

Last Name *

Birthdate *

Height *

Weight *

The team leader (parent who takes the responsibility of the dog)

First name *

Last name *

Contact info

Street + Nr. *

Zip Code + City *

Telephone Home

Telephone Mobile

Telephone professional

E-mail *

Where or how did you hear about Scale Dogs? *

Diagnosis

What is the official (full) diagnosis of the candidate *AutismAspergerPDD-NOSCDD (Heller's syndrome)

Please include a copy of the official diagnoses *

No file chosen

Degree *LowMediumHigh

Date of diagnosis *

Additional information

History of the child (The candidate)

Mobility *

Physical strength *

Response speed *

Balance *

Sight *

Hearing *

Speach *VerbalNon Verbal

Communication method (eg PECS, MAKATON, ...) *

Your child's sensitivities *

Sound *

Light *

Touch *

Other

Does your child exhibit runaway behavior? *YesNo

Does your child have a dominant color? *YesNo

Does your child have an obsession? *YesNo

Which one? *

How does your child deal with anger and / or frustration? *

Does your child receive medication? If yes, which? *

Is your child or other members of the family allergic to animals? *YesNo

do you have an idea about how you will deal with this? *

Level of activity of the child? *LowMediumHigh

Does the team leader (parent who will be responsible for the dog) work away from home? *YesNo

how many hours are they absent? *

What type of education does the child follow? *

Name of the school *

The child receives special guidance (1/1 guidance) at school *YesNo

Information team leader (parent who takes the responsibility of the dog)

First name *

Last Name *

Birthdate *

Amount of hours a day you spend with the child *

What are your expectations regarding the benefits that a dog can offer your child? *

Do you have any health problems / disabilities? *YesNo

please elaborate *

Do you have experience with dogs (grooming / training) *YesNo

Information regarding the living environment

Do you live *In the cityIn the suburbsIn a townother

Do you live *In a houseIn an apartmentOther

Do you have a garden? *YesNo

is it fenced? *YesNo

Where can the dog relieve itself? *

Do you have plans to move in the near future? *YesNo

Information regarding the family

List of all persons staying with the family (incl. Friends, care staff, ... if applicable). *Name, age and relationship

How would you describe the activity level within your family? *BusyMediumQuiet

Have you already discussed the request for a dog with the other family members? *YesNo

Does anyone have objections or doubts regarding the application of a dog? *YesNo

please explain *

Do you currently have other pets? *YesNo

which? *

Lifestyle child (candidate)

Do you think your child can do small exercises with the dog? *YesNo

Please describe the daily schedule (routines) and activities of your child below.

Monday *

Tuesday *

Wednesday *

Thursday *

Friday *

Saturday *

Sunday *

Additional information / comment

Which activities, which do not fall within the daily routine, does the child enjoy? *

Additional information team leader (parent who takes the responsibility of the dog)

Can you describe in your own words why you want an (autism assistance) dog for your child? *

How important is it for you to have a dog that has access everywhere (eg restaurant, shops, other public places, ...)? *

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