APPLICATION FOR SERVICE / COMPANION/ SEIZURE RESPONSE DOG
What is your primary disability: Autism Spectrum Disorder
What caused your disability and at what age? I’ve always had it and I don’t know what caused it.
Secondary disabilities: Epilepsy, ADHD, Auditory Processing Disorder.
Is your disability progressive? no
What are the effects of your disability?
Speech Impairment, Reduced Stamina, Coordination Problems, Slowed Development and Other: I can hear, but what someone says sometimes gets misinterpreted by my brain so I get confused and frustrated or worse. Also, when I am intently focused on something, I cannot hear what is going on around me. I have sensory issues, loud noises, smells, textures, being touched lightly and getting wet really cause me stress. I have trouble transitioning from activity to activity or place to place smoothly.
I have Allergies, Heightened Emotions, Depression, Seizures – partial complex seizures, occurring at night and not affecting daytime performance. I sometimes have fairly severe headaches (mostly from overstimulation).
I have been weaned off seizure medication but am being followed closely by my Neurologist, as my EEG’s are still abnormal.
I do not use any aids or assisting devices.
Neither I nor anyone in my family is in the military.
Pediatrician, Neurologist, Elementary School SLP omitted for privacy. Due to financial issues/insurance denial, I do not currently have speech or occupational therapy.
I live in a single family house on a ¼ acre with a fully fenced in back yard. Those I live with are my mom and dad, 3 younger sisters and 3 younger brothers.
I do not have an attendant.
I live in a quiet suburban neighborhood. I have tons of brothers and sisters, so our house isn’t always quiet and there are toys lying around. I rarely ever go to the park, stores, church, the mall, or beach because I just don’t feel safe there. There are no sidewalks, but not a whole lot of traffic on my street. Everything is too far away to walk to so mom drives the 15 passenger Ford E-350 van. Because it’s hot here we have shade trees. Oak and Mulberry trees are in the fenced in yard, along with the horrible pine tree that has sap and pokey pinecones. We have never seen any, but there are poisonous snakes in our part of the state. We have lizards, grass snakes, and tree frogs in our yard. In the summer we have little kiddie pools out in the back yard (1 ft deep at the most). We have a 4 bedroom/3 bath house. Rosalie and I sleep in the same room and she annoys me because she gets up all the time to tell everyone she’s scared of the dark. We go to the doctor’s offices sometimes and ride on elevators, but most every building is only one story around here.
We used to have dogs. My mom used to show, train and breed Soft Coated Wheaten Terriers and Tibetan Spaniels. We haven’t had them since I was 5, but I remember them! I LOVE DOGS. I was an excellent puppy socializer – I would play with them and put them in my tiny stroller and take them on walks around the back porch.
Do other animals live with you or visit you frequently?
The only pets I come into contact with are grandma’s dog and cat and Auntie E’s kitty. They don’t come to my house though. Katherine has an iguana in a locked cage.
My mom knows all about dog training and will be the main person helping me to train my dog. She will be the one who is responsible for setting up his/her routines and helping me follow through on those routines.
Does anyone in your household have concerns about having a service/companion dog in their home?
I will be thrilled to have a dog to help me out. Mom wonders about the burrs getting into the dogs fur, but when we ‘babysat’ grandma’s 10 year old Tibetan Spaniel , that wasn’t very difficult to deal with. My dad wonders how expensive it will be to feed/vet care the animals, since we pay for private school for me and 2 siblings. But overall, we are all excited about the idea. Mom has always said that once the last child is out of diapers she was going to be able to think about dogs again.
Are you allergic to animals? No, but several of us have environmental allergies, my little brother is on an inhaler daily for asthma, and we have an air filter system in our air conditioner to help with the allergies.
Bugs are part of life. We would use heartworm, flea and tick preventative year round here. We would spray our yard for bugs with the knowledge that the animals can get fleas from just about anywhere here in our town. Because I chew on my fingers when I get nervous, and because of my allergies to the stuff outside, I would prefer not to have a dog that sheds a lot. I will be trained to groom my dog, because dogs tend to shed year round here instead of seasonally. I’d like to keep that to a minimum.
I am currently a full time student at BA. This is a very small school, my teacher and principal are incredibly supportive and will do everything they can to help me grow – including incorporating my dog into my daily routine. Transitioning from home to school is hard for me – my behavior effects my family and peers; I take a long time to get acclimated to the school environment (interfering daily with learning). Having my dog accompany me would help me, my school and my family. Field trips to the retirement center across the street will become a much less stressful event when I have my assistant by my side. When I am in a sensory break at school, my dog could go with me and help me by lying on my lap or leaning on me to provide deep sensory input and the emotional help I would receive from him would be most calming. I sometimes do not keep appropriate distance from people. Having my dog there and having direct instruction from teachers and parents could help me by providing a visual reminder of how close I should be getting (“if your dog can’t stand comfortably between you and your friend, then you are too close”). My school does not use loud bells, and there are not any individual desks – we have portable tables that we move throughout the day to make our small (3 – 7 children) groups for different activities. We have a kitchen that we eat in, big kids, little kids, and even the teachers’ toddlers in high chairs. Every Friday is “fun Fridays” where we have ½ day of school and ½ day of nothing but fun activities. I think if I had a dog to bring to school with me, it would encourage my language skills and my social skills. It would boost my self esteem and confidence.
Pick five of the following words that would best describe the dog you would like to have.
- Loving, playful, calm, confident, sweet
Pick five of the following words that would describe traits you would not like to have in a dog.
- Indifferent, distracted, submissive, excitable, fearful
Are you available to attend a two week training camp at the Canine Assistants facility?
Absolutely. My teacher would let my mom do a modified home school type routine if it were during the school year (she home schooled me for 5 years). Dad has flexibility/vacation time at work but mom would be the main one to bring me. Our church family would be more than happy to support us by providing childcare/meals while we are away at training camp.
How do you feel a service/companion dog could improve your life? With what specific tasks would you hope a dog could help you? As I get older, I will want to become more independent. I think having a companion dog will help me get over my insecurities in public places. When I cannot hear clearly, like in a gym, a store or even outside, it is scary for me, but I have a really hard time saying that in words; usually if it bothers me a lot I act out. Currently I do not go to the grocery store, malls, or church. My dog will open up my world for me and allow me to go to the places I need to go to as I become an adult. Transitioning from one location to another will be easier because my dog is consistently with me – it will help me feel secure. When I am forced to go out and get overwhelmed, I cling to mom, even hang on her, as a means of trying to overcome my insecurities. I won’t need to do that when I have physical contact with my dog. I will become more confident of my own self, and when that confidence grows I will have more self esteem. I will be able to talk to other children about my dog, and that would have a positive effect on my social growth. I will have a buddy that loves me when it feels like the world is so disordered and chaotic. I will become more emotionally stable because I will always have someone right there to talk to who won’t say, “I don’t understand what you’re trying to say!” and won’t get angry at me for saying the wrong words. I will start becoming desensitized to things that really bug me like wet hands (let’s face it – dogs get wet a lot! Feet, face, water bowls… and I’m the one that will be dealing with that!). Having a dog to groom will give me a skill I can use to serve others and possibly give me a job skill as I get older. Plus it will give me something very positive to relate to my siblings with – maybe I can even teach my dog to go to them on command (they will be so happy to be part of the training)! All this would help my self-esteem and confidence – and I would finally feel like a ‘normal’ person!
Specific tasks that I think will be helpful for my dog to provide for me are:
-nudge me when he sees me chewing on my fingers. (I chew my fingers when I’m stressed).
-lean on me or lie on me on command for when I need a sensory break.
-if I have a command to give him that is just for him to touch me somehow – kind of like telling me that s/he is there and it’s ok, I’m not alone – I’d use this command if I am getting agitated and maybe that will help me get centered and refocus so it doesn’t escalate.
Please tell us a little more about yourself—hobbies, activities, clubs, interests, etc.:
I love Webkinz pets and the online Webkinz world. I have 38 Webkinz right now. I love horses and dogs, and I’m starting to become interested in pre-teen shows like sonicX and iCarly. I love taking videos of my Webkinz. I love being alone, but it is hard in a large family. I sometimes share my Webkinz when my siblings are being good. Can you tell I love Webkinz?
Because it is important to teach others about service dog teams, community service is all that we ask in return for a placed service dog. What kind of community service would be of interest to you?
My mom said that by the time I’m 16 maybe I can go stay with my Grandma and help her with her medicines, cooking, cleaning and errands. I wouldn’t mind going to retirement centers and doing some volunteer work there with my dog! I don’t have the same problems with adults that I do with other kids, so I get along with the adults best. The older people love dogs and I think a companion dog for someone like me (especially a loving, kind, calm dog) would be excellent to help the older people feel loved. I love serving, but it would be hard for me to do it without a dog by my side. Of course mom would have to go with me because I’m not old enough to go on my own.
Parent’s Signature: _______________________________ Date:_____________________