cstda

SERVICE APPLICATION FORM

IN CONFIDENCE WHEN COMPLETED
Should you feel uncomfortable to complete this form please call CSTDA +61 458458541 for advice and assistance
PARTICIPANT PERSONAL DETAILS
First Name Family Name

Address Street Suburb State

Marital Status Residential Status Gender Post Code

Single / Married / Partner Family / Alone / Carer Assisted /
/Divorced Care Unit / other
Tel – Home Tel - Mobile Tel - Business

Date of birth Email

DETAILS OF PERSON FILLING THIS FORM IF NOT THE PARTICIPANT

First Name Family Name

Name & Relationship to PARTICIPANT Is PARTICIPANT aware that you are applying for
a Therapy dog for them? Yes / No
Contact details if different to those above Code
Address Street Suburb State

Tel – Home Tel - Mobile Email

PEOPLE THAT ARE IMPORTANT TO THE PARTICIPANT

First Name Surname Relationship Telephone Email

A

Center for Service and Therapy Dogs Australia Pty Ltd.,26 Poplar Street, Caulfield South, Victoria, 3162
TEL - +61 458458541, WWW - http://cstda.com.au/ , @info@cstda.com.au, ABN – 21143697116
In the spirit of Reconciliation, CSTDA acknowledges Aboriginal and Torres Strait Islander peoples as the Traditional Owners and
Custodians of this country, and their connection to land, water and community. We pay our respects to them, their cultures and
customs, and to the Elders both past and present.
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PEOPLE WHO CARE FOR THE PARTICIPANT

First Name Family Name

Address Street Suburb State

Tel - Business Tel - Mobile Post Code

Therapeutic Relationship Email

First Name Family Name

Address Street Suburb State

Tel - Business Tel - Mobile Post Code

Therapeutic Relationship Email

First Name Family Name

Address Street Suburb State

Tel - Business Tel - Mobile Post Code

Therapeutic Relationship Email

First Name Family Name

Address Street Suburb State

Tel - Business Tel - Mobile Post Code

Therapeutic Relationship Email

Please note:
During the application process CSTDA will collect personal information about you. You will be required to
give permission for the CSTDA to contact people listed above. Collecting this information will enable
CSTDA to assess the potential impact of a service dog for the PARTICIPANT and to determine
individualised training requirements for the dog. Please refer to the informed consent within this form and
the company web page for the privacy policy.

Center for Service and Therapy Dogs Australia Pty Ltd.,26 Poplar Street, Caulfield South, Victoria, 3162
TEL - +61 458458541, WWW - http://cstda.com.au/ , @info@cstda.com.au, ABN – 21143697116
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CURRENT CONDITION
What is the current diagnosis, condition and medical history?

What support and aid systems are in place? Family support? Care workers? …

Center for Service and Therapy Dogs Australia Pty Ltd.,26 Poplar Street, Caulfield South, Victoria, 3162
TEL - +61 458458541, WWW - http://cstda.com.au/ , @info@cstda.com.au, ABN – 21143697116
 IN CONFIDENCE WHEN COMPLETED - PAGE 4

PARTICIPANT EDUCATION / OCCUPATION / HOBBIES & INTERESTS

Please list details of all schools & educational facilities attended by the PARTICIPANT (4 most recent)
Period
Facility From To Tel Number Contact if available

Please list details of all jobs / occupational positions held (4 most recent) N/A
Period Contact if available
Facility / Detail of work Tel Number
From To

List any Hobbies / Sports / Interests or other leisure activities pursued by the PARTICIPANT and the average amount
of time spent on it a regular week. Indicate if their condition hinders them from pursuing it more fully.
Activity Time Functionality

Does the PARTICIPANT have any experience or exposure to pets / animals (family or personal)

Does the PARTICIPANT have any preference for a dog size and breed? Please specify;

Does the PARTICIPANT have any allergies to animal hair or fur? Yes / No

Please list any past memorable / enjoyable experiences

Experiences / moments Year

Center for Service and Therapy Dogs Australia Pty Ltd.,26 Poplar Street, Caulfield South, Victoria, 3162
TEL - +61 458458541, WWW - http://cstda.com.au/ , @info@cstda.com.au, ABN – 21143697116
 IN CONFIDENCE WHEN COMPLETED - PAGE 5

EXPECTATIONS FROM THE CSTDA PROGRAM

How do you believe a service or therapy dog can assist you or the PARTICIPANT?

Have you participated in any other animal assisted therapy programs in the past? Yes / No No
If so please identify which programs and provide details;

What would you like to achieve from the program …. Goals …..

Are you aware that a Service or Therapy dog requires ongoing expenses, time, and effort to exercise, care for, provide
veterinary care and maintain their training? Yes / No

INFORMED CONSENT

As part of providing an Animal Intervention Empowerment Service, (SERVICE) to you, the Centre for Service
and Therapy Dogs of Australia (CSTDA) needs to collect and record personal information from you that is
relevant to your situation, such as your name, contact information, medical history and other relevant
information as part of providing these services to you.
● This collection of personal information will be a necessary part of the ASSESSMENT and SERVICE
that is conducted.
● Your personal information that is gathered as part of your assessment and intervention is kept
securely and, in the interests of your privacy, used only by the authorised personnel of the company.
● Your personal information is retained in order to document what happens during sessions and
enables the therapist to provide a relevant and informed service to you. A more detailed description
is provided in the company’s “Privacy policy”, which can be obtained by contacting
info@cstda.com.au. The Privacy Policy contains information about how to access and seek
correction of your personal information, and how to lodge a complaint about our management of
your personal information.
● You may, at any time, request that no information is collected or retained and all information be
destroyed and returned to you however this may negatively impact the level of service delivered.
During the assessment process your Interventionist will spend time with you reviewing the program and
privacy policy in more detail.
SIGNATURE

………………………………………………………………………….
……………………………………….
PARTICIPANT / FOR THE PARTICIPANT DATE

Center for Service and Therapy Dogs Australia Pty Ltd.,26 Poplar Street, Caulfield South, Victoria, 3162
TEL - +61 458458541, WWW - http://cstda.com.au/ , @info@cstda.com.au, ABN – 21143697116