Home
About Us
Programs
Facility information
Supporters
Contact Us
Donate

Home ››

Facility Application

Facility Application and Assessment Form

Facility Name: *

Contact details of your facility

Contact Person: *

Position: *

Postal Address: *

Suburb: *

State: *

Postcode: *

Phone: *

Fax number:

Email address:

Information about your facility

Description of the facility: *

Other:

If you have chosen other, please provide more details.

When would you prefer a Therapy team to visit: *

Weekdays

Weekends

Either of the above

Please tell us briefly why you would like to have a Delta Therapy Dog team visit your facility: *

Is there an attendance book for the Therapy team to sign in and out?: *

Yes

No

Please describe the floor surfaces: *

Slippery

Non-slippery

Tiled

Carpeted

Please chose more than one if required.

Can the Therapy team park on the grounds?: *

Yes

No - off street parking available

No parking available

Is there a garden area that could be used when taking the dog for a break?: *

Yes

No

About your residents

How many residents/patients are there in your facility?: *

What is the average age range of your residents/patients: *

Under 18

18-25

26-40

41-50

51-65

65-80

over 80

What are the most common illness experienced by your residents/patients: *

Assessment of your facility

Will a person from your facility accompany the therapy team?: *

Yes on all visits

Yes on the first few visits only

No

Is your facility...: *

Public

Private for profit

Not for Profit

Church/Community

Hospital

Other

Other:

If you chose other, please expand.

Are there any resident animals in your facility?: *

Yes

No

If you have a resident animal what type is it?:

Are there any other visiting animals?: *

Will the Therapy team be required to use...: *

Stairs

Lift

Neither

You may chose more than one option.

Will the Therapy team be visiting private rooms?: *

No

Yes

If the Therapy team is visiting private rooms, do you object to dogs being placed on residents beds?: *

Yes

No

Margaret Grice and Harry

Dog Trainer Course
Classroom Canines
Dog Safety

Find a dog trainer
Find a veterinary behaviourist
Facility information

Therapy Dogs
Volunteer reports
Contact Us

Volunteer stories
Volunteer awards
Volunteer news

Links
Supporters
Donate
Search

Copyright © Delta Society Australia