Autism Assessment Application Form

Parent Information - Mother
Name*
First Last
Email*
DOB
YYYY dash MM dash DD
Phone
Mobile
Work Phone
Street Address
Suburb
State
Postcode
Occupation
Employer
Employment Address
Parent Information - Father
Name*
First Last
Email*
DOB
YYYY dash MM dash DD
Phone
Mobile
Work Phone
Street Address
Suburb
State
Postcode
Occupation
Employer
Employment Address
Child's Information
Name*
First Last
Email*
DOB
YYYY dash MM dash DD

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Physician Information
Name*
Address*
Phone*
Email*
May we contact ?
Physical Therapist Information
Name
Address
Phone
Email
May we contact ?
Occupational Therapist Information
Name
Address
Phone
Email
May we contact ?
Speech Therapist Information
Name
Address
Phone
Email
May we contact ?
Psychatrist Information
Name
Address
Phone
Email
May we contact ?
Psychologist Information
Name
Address
Phone
Email
May we contact ?

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Diagnosis
What is the Primary Diagnosis for your child?
Are there additional medical problems/disabilities confronting your child?
Please provide copies of any assessments and/or medical reports undertaken by healthcare professionals regarding your child’s primary and secondary diagnosis e.g. Griffiths Mental Development Scale; Child Behavior Checklist- parent and teacher; The Childhood Autism Rating Scale (Cars), psychologist reports etc.
Drop files here or

Max. file size: 10 MB.
How does your child's condition addect their daily living skills?
What are your son/daughter's limitations?
Are there restrictions or precautions as a result of your child's diagnosis?
What type of medical/therapeutic/biomedical treatment is your child currently receiving?
What medication is your child currently taking?
Name of Medication Daily Quantity Purpose of Medication
What types of adaptive equipment does your child use (ie. Wheelchair, hearing aid)?

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Household Information
Is your familly split?
WIll the assistance dog be spending time in both residences?
What type of home does your child reside in (3 Bed, Villa, Other) ?
Do you Rent/Own/Other?
Landlord's Name
First Last
Landlord's Street Address
Landlord's Phone
Do you have a fenced yard?
Do you plan to fence the yard?
Who lives in the home?
Name Age Relationship
Are there pets in the home?
Species Name Age Gender Desexed Inside or Outside ?
Father's Family Environment
What type of home does your child reside in (3 Bed, Villa, Other) ?
Do you Rent/Own/Other?
Landlord's Name
First Last
Landlord's Street Address
Landlord's Phone
Do you have a fenced yard?
Do you plan to fence the yard?
Who lives in the home?
Name Age Relationship
Are there pets in the home?
Species Name Age Gender Desexed Inside or Outside ?

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Assistance Dog Placement
Who will be the primary handler of the dog?
Please provide as much info as possible including co-handlers and additional handlers
Will you be able to feed the dog the food stipulated by us ($50-$60 a month)?
Can your child participate in feeding the dog?
Can you bathe and groom the dog?
Can you afford to pay for dog grooming ($30-$70 3-4 times per year)?
Can your child participate in grooming the dog?
Can you afford to pay for veterinary services that will be required throughout the life of the dog?
If no to any of the above, please explain how these will be taken care of
What tasks do you think an assistance dog could do to aide your child?
Does your child want an assistance dog?
Why do they want an assistance dog?
Please record their answer to this question (if applicable)
Max. file size: 10 MB.
Do you want his dog to go to school with your child?
If so, discussed with appropriate teachers/administrators?
What was their initial response?
Child able to share and express their feelings about having an assistance dog?
How do you believe assistance dog will benefit you as parent/guardian?
If other children, what do they think of child with ASD having assistance dog?
Child with ASD needs to be primary caregiver of dog, this ok with rest of family?
Will you be able to cope with dog as a new addition to the family?
Anything else we should know?

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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.
Mother Parent Signature
Mother Parent Name
Father Parent Signature
Father Parent Name

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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.
Full Name
PARENT INFORMATION - MOTHER
Signature
Print Name
First Last
Address
Date
YYYY dash MM dash DD
PARENT INFORMATION - FATHER
Signature
Print Name
First Last
Address
Date
YYYY dash MM dash DD
CHILD'S INFORMATION

Parent or Legal Guardian
Signature
Print Name
First Last
Address
Date
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.
Full Name
First Last
Parent/Legal Guardian Name
First Last
Parent's Signature
Date
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:
Reference 1 Name
First Last
Reference 1 Email
Reference 2 Name
First Last
Reference 2 Email
Full Form Copy
Please enter the email address if you want to receive a copy of the full form submission as a PDF attachment
Email

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Name of Medication	Daily Quantity	Purpose of Medication

Name	Age	Relationship

Species	Name	Age	Gender	Desexed	Inside or Outside ?

Name	Age	Relationship

Step 1 of 9 - Family Contact Information

Parent Information - Mother

Parent Information - Father

Child's Information

Physician Information

Physical Therapist Information

Occupational Therapist Information

Speech Therapist Information

Psychatrist Information

Psychologist Information

Diagnosis

Household Information

Father's Family Environment

Assistance Dog Placement

FUNDRAISING AND PUBLIC RELATIONS STATEMENTS

RELEASE OF INFORMATION

Medical History Release

Reference Details

Full Form Copy