Canine-assisted Skill Building 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 skill building, please complete and submit this form. I will follow up with you to discuss scheduling services.

Referral Form

MM slash DD slash YYYY
Referring Agency(Required)
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.
Funding Source(Required)
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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