Smoky Mountain Service Dogs

Facilitating a Better Life For Veterans Through Canine Companionship and Service

Now Accepting Preliminary Applications

SMSD serves Veterans and First Responders with physical and psychological disabilities.

SMSD does NOT train dogs for:

Seizure alert/response
Diabetic alert/response
Guide dogs for sight issues
General disabilities

Our normal service area is a 350-mile radius or an approximate six-hour drive from Knoxville, Tennessee. SMSD serves the entire state of Tennessee and portions of Alabama, Georgia, North Carolina, South Carolina, West Virginia and Virginia regionally. Please note that we do have the ability to OVERRIDE the service area with SMSD board approval when the applicant meets the application criteria and is approved by the SMSD application team. For more information about our application process and how we operate, please read the https://www.smokymountainservicedogs.org/frequently-asked-questions/

Please read before submitting the Preliminary Application:

Confidentiality Agreement

Client Expectations

SMSD Grievance policy

All applicants must agree to a background check. A felony conviction or a conviction of a crime of domestic violence or animal abuse will result in disqualification. All other offenses will be evaluated based on their nature, severity, and recency.

Please provide the following information

Name *

Street Address

City

State

ZIP / Postal Code

How long have you resided at this address?

Phone Number *

Email Address *

Name of individual applying for service dog

Age

Height

Weight

If not the applicant, name of person completing this form and relationship to the applicant:

Type of Applicant *VeteranFirst Responder

For Veteran Applicants

Branch

Service End

Service Start

Type of Discharge

Rank at Discharge

For First Responders Applicants

Public Service Agency

Title/Rank

Service Start Date

Service End Date

Reason for Leaving

Contact Name and Phone Number for Employment Verification Purposes

All Applicants, Complete the Following Information

List your physical disabilities0 / 180

Are any of these physical disabilities service connected? Describe below.0 / 180

Describe how your physical disabilities affect your daily life0 / 180

Considering your physical disabilities and physical limitation, describe specific tasks you feel a service dog could do for you that would assist you in your activities of daily living such as picking up dropped items etc.0 / 180

Check items you currently use for mobility assistance

CaneWalkerWheelchairMotorized chair or scooter

Do you have any psychological disabilities? (PTSD, Depression, Anxiety, Bipolar, OCD, etc) Describe all below.

Are any of these psychological disabilities service connected?

Are you currently under the care of a Mental Health Provider?YesNo

Describe how your psychological disabilities affect your daily life.

Explain why you feel a service dog would be helpful to mitigate your psychological disabilities.

If you have a PTSD diagnosis, please complete the following questions:

Have you ever been suicidal? have suicidal or homicidal ideation?YesNo

If yes, have you sought help?YesNo

Are you currently in a treatment plan with a mental health provider?YesNo

If yes, describe what your treatment includes such as grounding techniques, medication, deep breathing, counseling

Have you completed 6 months of consistent treatment?YesNo

If no, please explain

Have you been compliant with attending all appointment sessions as well as with treatment plans?YesNo

Have you been in an inpatient treatment facility in the past 12 months?YesNo

If yes, please give details of the reason for hospitalization

Identify a support network such as family and friends who can and will assist you in difficult times:

Are you willing to sign releases for SMSD representatives to communicate with your: a) mental health provider b) your support network of family or friends, and, c) your PCP if warranted regarding physical disabilities?YesNo

Have you discussed a psychiatric service dog with your mental health provider?YesNo

Have you ever injured/hurt a person or animal?YesNo

If yes, please explain

Do you have now or in the past had substance abuse issues?YesNo

If yes, do you attend an ongoing -recovery program such as AA or VA substance abuse programs?YesNo

If yes, name the program and how often you attend

If no, would you be willing to enroll in some type of on-going recovery program?YesNo

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Please click below and read the details of this disclosure before signing authorization.

Authorization for Use or Disclosure of Protected Health Information

I voluntarily authorize release of my confidential protected health information for use by SMSD Application team as needed to determine my eligibility for a service dog as required by their application criteria. I have read the details disclosed on the link provided. This authorization expires in one year from the date below.

Signature *type your name

Now Accepting Preliminary Applications

Please provide the following information

For Veteran Applicants

For First Responders Applicants

All Applicants, Complete the Following Information

Check items you currently use for mobility assistance

If you have a PTSD diagnosis, please complete the following questions:

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