Service Dog Application | Heeling House

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Service Dog Application

Please take a moment to fill out the form for your interest in a service dog. A staff member will be in touch shortly via email.

Full Name

Email

Phone

Address

Please list names and ages of all household members, along with any medical diagnoses for each and any allergies present

I am interested in a:

Psychiatric Service Dog

Autism Service Dog

Mobility Service Dog

Owner-Train Program

What service or tasks would you like the dog to provide and for whom?

Do you have any breed or size preferences? If so, what are they?

Thanks for submitting!

CONTACT

First Name

Last Name

Email

Phone

Subject

Message

Thanks for submitting!

20789 Great Falls Plaza #170

Sterling, VA 20165

Mail: mail@heelinghouse.org

Tel: 703-661-6610

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