Mutts With A Mission First Responder Service Dog Application

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Hero's Welcome

Thank you for your interest in Mutts with a Mission (MWAM). We provide Service Dogs for line of duty related Post Traumatic Stress Disorder (PTSD), traumatic brain injury (TBI), and mobility impairments for Law Enforcement, First Responders (Fire, EMS, etc.), and qualified Federal Employees with documented line of duty connected disabilities. If applying for a Service Dog for PTSD, applicants must have a verified clinical diagnosis for PTSD. MWAM does not train guide dogs or hearing dogs.


Please do not let the length of our application discourage you from applying and potentially receiving a life changing Service Dog. We want to ensure you receive the best experience through our program. Please fill out the application honestly and accurately. This application is the first step in regaining the independence you sacrificed serving our country. Please note that a Service Dog does not replace treatment but is another modality in addition to treatment.


Mutts With A Mission asks that all application responses reflect your own experiences and understanding. While tools that assist with spelling or grammar are acceptable, responses should be written in your own words so our team can better understand you and your needs. Some answers may be discussed during the interview process.


You must meet seven basic criteria to qualify for our program (we may require other criteria on a case-by-case basis):


● Disability must be line of duty connected

● Separated from service in good standing from a public agency or current good standing

● Verifiable line of duty connected diagnosis of PTSD, TBI, and/or a mobility disability

● Have a stable living environment

● Free of substance abuse. Using Marijuana, smoking, vaping, is not allowed in the dog's environment.

● No conviction of a crime against animals or any abuse (human or animal).

● Must be actively participating in a treatment program or under the treatment of a consistent mental health professional for a minimum of six months (for applicants requesting a Service Dog for reasons other than mobility).


It is important to note that we are not a residential treatment program. While we provide the necessary training and support, you are responsible for transportation to and from our two-week long Transfer Camp. We understand this may be a challenge for some, but it is a necessary part of our program's structure. If you are traveling from out of the area, we will pay for your hotel accommodations. You are welcome to bring one support person, however it will be at their expense.


Once the application is received, our Selection Committee, composed of experienced professionals, carefully evaluates each application to ensure completion. After the review, we will notify you of the next step in our application process. Please submit a completed application packet rather than one in pieces. If MWAM receives an incomplete application, you have until the submission deadline to submit the missing information.

MWAM will NOT require you to participate in fundraising or public relations activities unless you voluntarily consent.


Thank you for your service and sacrifice,


Brooke A. Corson

Executive Director


What To Expect
Applicant Status Begins

  • 1 June - 27 February: Welcome to complete an Application Interest Request Form online outside of Open Application, 3/1/2026-5/31/2026.
  • 1 March: Open Application available online. Email will be sent with link to individuals who previously submitted an Application Interest Request Form online.
  • 31 May: Completed applications are due. No late or incomplete applications will be considered.
  • 1 June - 31 July: Applications will be reviewed and interviews will be set up for qualifying applicants.
  • August: Interviewed applicants will be notified of the selection committee’s decision. (There are three types of decisions: acceptance, conditional acceptance, or denial.)
  • MWAM reserves the right to remove any applicant from the training program, at any time, for any reason.

    Candidate Status Begins

    • Denied candidates will be notified formally by email.
    • Conditional candidates must follow through with clear requirements and report back to MWAM within the designated period working toward Accepted candidate status. Conditional candidates who do not report back or do not meet MWAM requirement criteria will be dropped. 
    • Accepted candidates will be welcomed to the MWAM Waitlist for a Service Dog following a panel interview, or as the follow up review of a Conditional candidate. Upon notification, candidates must submit updated medical/mental health information. Accepted candidates must contact MWAM on a quarterly basis to indicate continued expressed interest in continuing, as well as will be required to provide updated medical information every six months.
    • Transfer Camp dates for selected candidates will be provided by MWAM. 
    • Candidates confirm planned participation in Transfer Camp.

    MWAM Team Status Begins

    • Applicant completes assigned book study prior to the start of Transfer Camp.
    • Applicant successfully completes two-week Transfer Camp.
    • Team passes MWAM certification tests.
    • Team graduates.
    • Team fulfills first-year responsibilities, including participation in all required check-in conferences.
    • Team keeps the lines of communication open and contacts MWAM regarding any questions or concerns.
    • Team schedules an appointment for annual recertification.
    • Team returns to MWAM every 12 months for recertification (this is at the recipient’s expense and may not be done virtually).
    • At annual recertification appointments, the team participates in certification testing, turns in a current copy of veterinarian records, completes all required paperwork, and sets an appointment for next year’s recertification. 
    Application Requirements
    Mutts With A Mission requires the following items before an application is reviewed.

    ·    COMPLETED APPLICATION MWAM will not accept medical forms dated more than 30 days before the date of the application.   


    ·    TWO RECOMMENDATION LETTERS These are character recommendations and should not be completed by a family member. These will need to be available to upload within the application.


    ·    TWO SERVICE DOG CARE CONTINGENCY AGREEMENTS These will be emailed from within the application to the 2 individuals to complete, sign, and click "submit." MWAM will receive the submission to add to your application.


    ·    CURRENT PHOTO This will need to be available to upload within the application.


    ·    DRIVER'S LICENSE PHOTO This will need to be available to upload within the application.


    ·    LINE OF DUTY DETERMINATION LETTER  A letter from your administrative department stating employment status at the time of injury and/or disability. 


    ·    PRIMARY BEHAVIORAL HEALTH QUESTIONNAIRE, if you are applying for a Service Dog for psychiatric disabilities or dual purpose. This form will be sent directly to your Mental Health provider via an email address provided within the application. It will help to have the email address available.

    V   

    ·    SIX MONTHS OF MENTAL HEALTH RECORDS, if you are applying for a Service Dog for psychiatric disabilities or dual purpose these records need to be provided by your provider and sent directly to MWAM. If you or your provider have a challenge with uploading your health records, please email to apply@muttswithamission.org with your name and phone number included in the email.    


         HEALTH RECORDS
    Physician notes on appointments and treatment for 2 years prior to applying. The can generally be obtained by a Release of Information provided by your provider's office. 

    ·    

         VIDEO: 

    Provide a YouTube link that has been made accessible to anyone with the link of the interior & exterior of your home & outdoor space, introduce us to any family members, roommates, pets, your workplace, and/or any other places where you spend most of your time.
    Please note that photos are not acceptable as a replacement for a video.

         

         $300.00 APPLICATION FEE: Paid as online donation www.muttswithamission.org 



    Page 2

    Applicant Information

    *** Incomplete applications will not be accepted. Please fill out completely and legibly ***







    SSN IS REQUIRED FOR BACKGROUND CHECK PURPOSES. APPLICATIONS MISSING SSN WILL BE REJECTED



    Current Physical Address





    Previous Address



























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    Household Information

































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    Medical Information















































    Page 5

    OQ-45 Form

    OQ-45 INSTRUCTIONS: 

    Looking back over the last week, including today, help us understand how you have been feeling. Read each item carefully and circle the number which best describes your current situation. Circle only one number for each question, and do not skip any. If you want to change an answer, please “X” it out and circle the correct one.


    Rating Scale:
    0 = NEVER, 1 = RARELY, 2 = SOMETIMES, 3 = FREQUENTLY, 4 = ALMOST ALWAYS














































    Page 6

    Adverse Childhood Experience (ACE) Questionnaire

    Please select YES or NO for each question.

    Prior to your 18th birthday:













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    Medical Provider Treatment Information



    Physician #1 Contact Information



    Physician #2 Contact Information



    Physician #3 Contact Information



    Mental Health Professional Contact Information








    Section 5

    Section 5: Medical History

    Applicant: Your Primary Care Physician or Specialist should complete and return this form directly to Mutts With A Mission (MWAM). If you would like recommendations from additional specialists to be considered regarding your disability, they will also need to complete and return this form. If you are applying for a Service Dog for PTSD or psychiatric disabilities, you will also need to complete the Primary Behavioral Health Questionnaire in addition to Section 5. Please sign and date this form prior to giving it to your healthcare professional.

    Physician's Release:



    Please release the requested medical information regarding my condition or disability to MWAM. MWAM will use this information to determine if a Service Dog would be an effective modality of treatment for my disabilities. Thank you.


    Physician Contact Information






    Patient's Status









    Physician initial required

    Note: Please send a copy directly to MWAM at apply@muttswithamission.org. MWAM will NOT accept a hand-delivered copy from the applicant.


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    Medical History

    Applicant: Your Primary Care Physician or Specialist should complete and return this form directly to Mutts With A Mission (MWAM).  

    If you would like recommendations from additional specialists to be considered regarding your disability, they will also need to complete and return this form.

    If you are applying for a Service Dog for PTSD or psychiatric disabilities, you will also need to complete the Primary Behavioral Health Questionnaire in addition to this Medical History. Please sign and date this form prior to giving it to your healthcare professional.


    Physicians Release:



    Please release the requested medical information regarding my condition or disability to MWAM.

    MWAM will use this information to determine if a Service Dog would be an effective modality of treatment for my disabilities.





    Physicians:
    Please be assured that completing this form does not create any liability for you.
    Your answers will be kept confidential.
    It is simply intended to provide relevant information and does not hold you responsible for any outcomes related to the applicant’s request.
    Thank you for your time and assistance.






    Patient's Status
















    Activities of Daily Living (ADLs)

    Please circle an answer for each statement.










    Overall Patient Assessment

    Please circle an answer for each statement.











    Page 8

    HIPAA Authorization

    ***Authorization for Use or Disclosure of Protected Health Information***
    (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)



    I hereby authorize (healthcare provider(s) stated below) to use and disclose the protected health information related to my complete health records; including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse; to Mutts With A Mission (MWAM) for the purpose of applying, placement, and/or recertification of a Service Dog.

    I understand that I may inspect or copy the protected health information described by this authorization.

    I understand that, at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my healthcare and the payment for my healthcare will not be affected if I refuse to sign this form.

    I understand that information used or disclosed, pursuant to this authorization, could be subject to redisclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.



    Type your full name to indicate your electronic signature


    If no date or event is stated, the expiration date will be six years from the date of this authorization.

    Page 9

    Emergency Information

    Personal Information




    Who should Mutts With A Mission (MWAM) notify in case of emergency?















    Page 10

    Legal History 

    It is the policy of Mutts With A Mission, Inc. (MWAM) to conduct a background check on all applicants. Being charged with or convicted of a crime is not always a disqualifier.













    Page 11

    New Applicant Letter of Agreement

    Mutts With A Mission (MWAM) provides specialized trained Service Dogs for Veterans with disabilities. Upon acceptance as an applicant of MWAM, you must meet certain obligations.

    This New Applicant Letter of Agreement defines those obligations required to maintain the high standards required by Assistance Dog International (ADI) and MWAM's Service Dog program.

    1. My goal in applying to become a MWAM applicant is to be paired with a MWAM Service Dog.
    2. I agree to attend all classes unless I notify MWAM staff and my trainer before class, and a MWAM staff member excuses me. Two unexcused absences may result in dismissal.
    3. I agree to practice exercises learned in class at home each day.
    4. I agree to come to class prepared.
    5. I agree to use humane training methods and training tools.
    6. If I do not understand a particular idea presented in class, I agree to discuss my concerns with my trainer.
    7. I agree to keep my dog healthy (to include a proper weight) and to groom him/her regularly.
    8. I agree to be the primary caretaker of my dog.
    9. I agree to leash my dog in class or public unless instructed otherwise.
    10. I agree to clean up after my dog when out in public.
    11. I understand that the community has a right to expect my dog to always be under control and not to be intrusive at any time.
    12. I understand that whenever I am out in public with my dog, I represent MWAM. I will not intentionally create a negative reflection on the program.
    13. When the opportunity presents itself, I agree to assist in educating the community, in a non-confrontational manner, on the benefits a person with a disability receives using a Service Dog.
    14. I agree to assume liability for any damage my dog might cause to people or places.
    15. I acknowledge that my dog and I must meet the ADI and MWAM standards to become a MWAM Service Dog team.
    16. I understand that failure to follow the requirements can result in the removal of the dog.

    Type your full name to indicate your electronic signature

    Applicant's Rights

    It is the policy of Mutts With A Mission (MWAM) that all applicants have the right to:

    • Be treated with respect and dignity
    • Receive complete information regarding the application, rules, and responsibilities
    • Receive complete information and training on all aspects of assistance dog partnership, training, medical care, and maintenance
    • Be able to call MWAM for assistance whenever needed.
    • Receive updates on MWAM Team policies and procedures related to applicants, candidates, and graduate Teams.
    • Expect MWAM staff to keep their files and personal information confidential and private unless the applicant gives written permission. MWAM keeps this permission in the applicant's file.

    Type your full name to indicate your electronic signature

    Page 12

    Signature and Certification


    Please initial each statement to acknowledge your understanding.














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    Primary Behavioral Health Questionnaire


    To be completed by LCSW, LISW, LPC, PSYCHOLOGIST, or PSYCHIATRIST


    Request: 

    The Applicant above has applied to Mutts With A Mission (MWAM) for a Service Dog.

    MWAM requires this form to be completed by their primary mental health provider to release of medical information regarding their condition or disability to Mutts With A Mission (MWAM). MWAM staff and its mental health professional partner will use this information to determine if a Service Dog would be an effective modality of treatment for them.


    Please complete and return this form electronically to Mutts With A Mission via the Submit button at the end. 


    Note to Provider:

    Please be assured that completing this form does not create any liability for you. Your answers will be kept confidential. MWAM has a Mental Health Provider on the Selection Committee who reviews the mental health information and assists with interviews. This form is for fact-finding purposes only, and MWAM does not hold you responsible for any outcomes related to the applicant’s request. Thank you for your time and assistance.


    If you have any questions or concerns, please feel free to contact MWAM at apply@muttswithamission.org or (757)465-1033 - Application Coordinator.

    Provider Contact Information





    Questionnaire Section















































    Page 13

    Service Dog Care Contingency Agreement

    Applicant needs to provider 2 emergency contacts who are willing to care for the Service Dog, temporarily, if needed. MWAM will assist as needed and remain on standby 24/7.


    Please provide the name, phone number, and email of your 2 requested emergency contacts below. By doing so, they will be emailed a form to complete.  When they click submit on the form, the information will be sent directly to Mutts with a Mission.

    Service Dog Contingency Contact 1



    Service Dog Contingency Contact 2



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