Request for Animal Assisted Intervention

Client's Full Name *

Name of individual completing form *

Relationship to client *

Name of Animal *

Age of Animal *

Type and Breed of Animal *

Please briefly describe how you wish the animal to be incorporated into your child’s therapy sessions: *

I understand that my current therapists have the right to request not to participate io Animal Assisted Intervention (AAI) at any time, and that in that event I have the choice to change to an alternative therapist if available OR to continue planned therapy services without the animal intervention component. *

I confirm that my animal has undergone all necessary training and temperament checking and is deemed suitable and safe to be involved in a therapy session. *

I understand that I remain liable for any damages the animal may cause to a person or property.
*

Do you wish to have the animal enter the Next Challenge premises (Unit 1 and 4 / 14 Main St, Osborne Park)? *

No - only to be incorporated into my child’s services based at home or in the community.Yes - I would like the leasor of the premises to consider allowing access - I understand Next Challenge will apply for this approval confidentially on my behalf without using my name or child’s name but will need to provide the leasor with a brief outline of this request, the type and age of the animal and the level of training it has attained.

To allow us to request access to Next Challenge premises, please detail the type of training/ temperament assessments your animal has undertaken: *

I confirm that my animal has current vaccinations and health certifications, and that all necessary health regimes such a flea treatments are being maintained.

Signature *

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Date *