Righteous Pups
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Autism Assessment Application Form

Step 1 of 9 - Family Contact Information

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  • Parent Information - Mother

  • YYYY dash MM dash DD
  • Parent Information - Father

  • YYYY dash MM dash DD
  • Child's Information

  • YYYY dash MM dash DD
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  • Physician Information

  • Physical Therapist Information

  • Occupational Therapist Information

  • Speech Therapist Information

  • Psychatrist Information

  • Psychologist Information

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  • Diagnosis

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    Max. file size: 10 MB.
    • Name of MedicationDaily QuantityPurpose of Medication 
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    • Household Information

    • NameAgeRelationship 
    • SpeciesNameAgeGenderDesexedInside or Outside ? 
    • Father's Family Environment

    • NameAgeRelationship 
    • SpeciesNameAgeGenderDesexedInside or Outside ? 
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    • Assistance Dog Placement

    • Max. file size: 10 MB.
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    • FUNDRAISING AND PUBLIC RELATIONS STATEMENTS

    • Our family is aware that Righteous Pups Australia Inc, is a non-profit organization that relies on donations and fundraising to continue to breed, raise, train, place and provide annual follow ups of the Autism Assistance Dogs and that each dog is valued at well over $29,000.00

      Our family is aware that we will not be required to participate in fundraising or any public relations without our voluntary permission

      Our family is aware that we may be asked to participate in fundraising for Righteous Pups Australia Inc.

      Our family understands that RPA Inc is entitled to remove an Autism Assistance Dog once the dog has been placed with the recipient family, if we:
      i. Mistreat the assistance Dog.
      ii. Don’t take the appropriate care for the assistance dog
      iii. Don’t use the assistance dog for the primary tasks it has been placed for.
      iv. Don’t complete a yearly public access test.
      v. Are found to abuse drugs, alcohol and/or animals.
      vi. Have provided false information pertaining to any circumstances.
      vii. Do not continue with RPA Inc, advice and training protocols.
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    • RELEASE OF INFORMATION

    • I consent and request you to supply Righteous Pups Australia Inc, with any medical, social or criminal information which you may have, that is based upon your knowledge of, or records about, me or my child.

      This information is part of the necessary data to complete my application for an Assistance Dog for my child with Autism Spectrum Disorder so a dog can be trained and certified by Righteous Pups Australia, Inc.

      This information is designed to help Righteous Pups Australia, Inc to understand and assess my request for an assistance dog for my child with Autism Spectrum Disorder. Any copy of this form and signature may be used as an original for release of information purposes.

      This release also gives Righteous Pups Australia Inc written permission to conduct any, and all, background checks into my character e.g. police check.
    • PARENT INFORMATION - MOTHER
    • YYYY dash MM dash DD
    • PARENT INFORMATION - FATHER
    • YYYY dash MM dash DD
    • CHILD'S INFORMATION

      Parent or Legal Guardian

    • YYYY dash MM dash DD
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    • Medical History Release

    • I do hereby consent and request you supply Righteous Pups Australia Inc, with any medical and, or social information which you may have, that is based upon your knowledge of, or records about, my child, myself or my immediate family.

      This medical history form is a vital part of data needed to complete my application for an Autism Assistance Dog for my child so they are able to determine whether my child meet the eligibility criteria for an assistance dog.

      I would appreciate it if you could complete the attached form and attach any medical records you might have, including reports from specialists, and mail these documents to Righteous Pups Australia Inc, Po Box 429, Golden Square, Victoria 3555.

      This information is designed to help Righteous Pups Australia Inc, to understand and assess my request for an Autism Assistance Dog. These dogs are trained to:

      1. find a child who has wandered off and has little or no sense of danger, 2. aide in the development of a child's communication, behaviour and social interactions, 3. buffer anxiety and stress enabling the child to access public environments, and 4. provide companionship to a child with ASD.

      For more information on Righteous Pups Australia Inc, please visit our website www.righteouspups.org.au

      Any questions regarding this form should be directed to Righteous Pups Australia Inc and all information will be kept private and confidential.
    • YYYY dash MM dash DD
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    • Reference Details

    • REFERENCES: Please provide the Names and email addresses of two independent people not related to you, nor within your friendship circle. We will ask them to complete the following reference letter and return it directly to Righteous Pups.

      Fields below:
    • Full Form Copy

      Please enter the email address if you want to receive a copy of the full form submission as a PDF attachment
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