Retrieving Independence

Service Dog Application

* First Name

* Last Name

* Email

* Phone

* Address

* City

* State

* Postal Code

Gender

Preferred Pronouns

* Birthday

* What is your approximate height and weight?

We are excited that you are considering a service dog and have come to Retrieving Independence. Included is all the information you will need to gather and submit to begin the evaluation process.

Before you complete the application, we want to make sure you have all the information needed to make your decision to pursue a service dog through our organization.

When we receive your completed application package, the first step of the application process will be complete.

The second step is an interview, either in person or over the phone. The interview is crucial in helping us understand your needs, personality, and lifestyle which will greatly assist us in matching you with a dog. The last step is the hardest – waiting for your dog! Due to the high demand for service dogs at this time, the wait can be anywhere from 6 months to 2 years or more, depending on your needs and our current available dogs.

Thank you for your understanding. Please do not hesitate to reach out with any questions or concerns.

Please confirm that you understand:

The total investment of an RI service dog is $50,000. Through generous donations we are able to offer our dogs below that cost. I understand my contribution to the total expense of an RI service dog is a minimum of $15,000 (for dogs placed in 2026).

I understand that a deposit of $5000 is required after application review to move forward. The remaining balance of $10,000 will be due in installments before training camp begins.

I understand that I will be required to attend a 7-day training camp in Nashville Tennessee and I will have someone (adult, no children) accompany me through the entire camp.

I understand that to be considered for placement, the RI application review team must have access to my medical care team (this includes mental and physical health professionals).

I understand that RI retains ownership of the service dog for the lifetime of their working career and can remove the dog if the care and conditions do not meet our standards.

I understand that if I am unable to care for my service dog or no longer need a service dog, RI will be notified immediately and I will be responsible for transporting the dog back to RI.

I understand that an RI service dog is never to be sold or placed in another home without express consent from RI.

Are you applying for a successor service dog?

If applying for successor service dog, what is your retired dog's name and year received?

* What is your primary disability:

* What caused your disability and at what age:

* Please list any secondary disabilities, if applicable: Is your disability progressive?

Please check all that apply: What are the effects of your disability?

Other:

Do you have problems with:

If you checked yes on seizures, what type and how often are your seizures?

What treatments or medications are you using or have you used to control your seizures?

Do you use any of the following aids or assisting devices?

Other aids or devices:

* Are you active in the military, a veteran, or a dependent of an active military or veteran? Please explain.

* Primary Care Physician, PT, OT and/or other health professionals important to your care: Name and Phone Number listed for each

* Do you live in:

If Other is selected please explain:

* Is your yard:

* Please list all members of the household: Name, Age, and Relationship

* Do you have an attendant?

If yes, are they:

* Please describe your home and your neighborhood (i.e. quiet, children frequently visiting, close to retail or commercial areas, suburban, rural, heavy traffic/main street, etc.):

* Does anyone in the household smoke?

* Have you ever had a pet dog before? If so, please list all pet dogs and how long you've had them.

* Do any other animals live with you, or visit you frequently?

* Have you ever experienced any trauma from a dog you owned, or a dog you were around, that could negatively impact your relationship with a service dog?

If yes, please explain what happened.

If so, please describe (include breed, age, etc.) - who is responsible for the care of these animals?

* Who will assist in the daily care and training of your dog, if needed?

* Does anyone in your household have concerns about having a service dog in their home? If so, please describe:

* Are you (or anyone in your household) allergic to animals?

* Are you (or anyone in your household) concerned about shedding or dog maintenance and care?

* Are you currently employed?

* If yes, who is your employer? Do you want your dog to assist you while at work? In what way?

* Are you currently in school?

If yes, where? Do you want your dog to assist you while in school? In what way?

Have you discussed with your employer/administrators/teachers about having a service dog with you?

Are they supportive?

* Pick five of the following words that would best describe the dog you would like to have:

* Describe your means of transportation:

* Are you able to attend a one-week training camp in Nashville?

* How do you feel a service dog could improve your life? What specific tasks are you hoping a service dog could help you with?

* Please tell us a little more about yourself - hobbies, activities, clubs, interests, etc.

* List 5 words that would describe your personality.

* What are short and long term goals that a service dog could help you achieve?

Do you plan on moving within the next year or time within applying for your Service Dog and graduating with your Service Dog? If yes, explain why and where.

We commit to the equitable treatment of every staff member, volunteer, inmate trainer, potential and current recipients, and of the broader community we serve.
We commit to show respect and acceptance, with a focus on celebrating the unique perspectives we all bring to the organization.
We acknowledge and honor the fundamental value and dignity of all individuals.
We strive to eliminate discrimination in all its forms.
We vow to use our voice to speak out against injustice and protect those who are under resourced, under-represented, and marginalized.

Application for a Service Dog

Please make sure your application is complete before submitting. Incomplete applications cannot be considered.

To complete your application please email the following to: jen@riservicedogs.org

Applicant Signature Page (attached below)
Applicant Support System Form (attached below)
RI's Clients Rights and Responsibilities (attached below)
Physician Medical Release Form (attached below)
Reference Letters

1 Professional - From an employer, teacher, colleague, therapist/provider, etc.
1 Personal - From a mentor, friend, roommate, classmate, etc.

Once these documents are submitted, please pay the $200 application fee to finalize your application:

Application Fees can be paid online here or by check .
Checks should be to be made out to Retrieving Independence Inc. and mailed to

Attn: Retrieving Independence
2400 Clifton Avenue
Nashville, TN 37209

Please reach out to us if you have any questions and we look forward to reviewing your application!

Retrieving Independence

Service Dog Application

Application for a Service Dog

Downloads

Applicant Signature Page

Applicant Support System Form

Retrieving Independence Clients Right and Responsibilities

Physician Medical Release