Active DutyRetiredVeteran Does anyone in the family suffer from allergies? YesNo Do you currently have dogs? YesNo Are you currently employed? YesNo Diagnosis (Check all that apply): PTSDTBIAdditional Mobility Issues (i.e. back pain) Help Us Secure Funding: The purpose of these questions is to gather data that could be helpful when providing anonymous statistical information for program funding opportunities. Your answer is voluntary, and in no way affects your eligibility for enrollment. Gender FemaleMale Branch ArmyNavyAir ForceMarinesCoast GuardNational Guard Ethnicity: CaucasianAfrican AmericanAsianHispanicNative AmericanOther Insurance Provider (check all that apply): VAMedicareMedicaidBCBSOther Annual Household Income: $0-$18,000$18,000-$25,000$25,000-$32,000$32,000-$40,000$40,000-$50,000$50,000+ I understand that the Hope Lives Here program, if enrolled, takes 9 to 12 months to complete. The program requires attendance to multiple weekly sessions, including, but not limited to, training, workshops, and so on. Hope Lives Here gives the option to have my own dog assessed for the program if it meets the age, size, and health requirements. If I adopt a dog through the program, I understand Hope Lives Here obtains dogs from local shelters. Dogs adopted from shelters are taken home the day of adoption with no previous service dog training.