Canine-assisted Skills and Wellness Referral Form

If you are a La Crosse County CCS or CLTS service facilitator and wish to refer a client to Crimson Hound for canine-assisted skills and wellness, please complete and submit this form. I will follow up with you to discuss scheduling services.

Canine-assisted Skills & Wellness Referral Form for CCS & CLTS

If you are a services facilitator with CCS or CLTS, please use this form to refer your clients for Animal-assisted Skills & Wellness sessions.

MM slash DD slash YYYY
Referring Agency(Required)
Funding Source & Type of Service Requested(Required)
MM slash DD slash YYYY
Address(Required)
Species of Pet(Required)
What kind of animal will we be working with?
A copy of the rabies certificate will be required at intake and when updated,
Preferred Days for Sessions (check all that apply)(Required)
Sessions take place in the client’s home or community.
Preferred Time of Day(Required)
Days/times are not guaranteed, but will attempt to accommodate if possible.
Who is requesting this service for the client?(Required)
This is an important factor in the success of this service. A client who is not on board, is less likely to want to participate during sessions and can have negative impacts on the relationship between client and dog.
This field is for validation purposes and should be left unchanged.

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