Submit an enquiry

Register of Interest Form

To make an enquiry about an assistance dog to help a child with autism please complete the register of interest form below. Please be aware that our autism project is still in its pilot phase, however submitting this form will ensure that your contact details are held and allow us the opportunity to contact you as the scheme allows.

A more detailed information sheet for parents considering our autism assistance dog programme is available in PDF format by clicking here.

Parent's Information

Title of parent *

Parent's first name *

Parent's surname *

Address *

Line 1
Line 2
Town
County
Postcode
Country

Telephone no *

Mobile

Email address *

Children's Information

Child's first name *

Child's surname *

Date of birth (Autism project is open to children aged between 3 - 10 years) (dd/mm/yyyy) *

Has your child been clinically diagnosed? *

Yes

What is the full dianosis? *

Autism

PDD

Aspergers

Other

If other please state:

Does your child display sensitivities, please tick all that apply: *

Sound

Light

Touch

Other

Please state other sensitivities:

Method of communication: Eg: Verbal or Non-verbal *

In your own words please describe why you would like an assistance dog (200 words max) *

Additional services

Dogs for the Disabled is also keen to hear from families that would like to attend short courses to help them select the right pet dog and / or get the most out of a relationship between a pet dog and their child with autism. If you should like more information about this then please check the box below. Please note, all fully-trained assistance dogs would come from Dogs for the Disabled's own training scheme. Pet dogs would not be able to receive public access rights or full assistance dog status.