| Your Name: |
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| Your Title: |
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| Facility Name: |
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| Address Street: |
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| Type of Facility: |
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| What populations does your agency/facility serve?: |
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| City: |
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| State: |
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| Zip Code: |
(5 digits) |
| Daytime Phone: |
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| Other Phone: |
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| Email: |
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| How often would you like teams to visit?: |
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| What days and times would best suit your needs? |
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| How long would you like each visit to last?: |
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| Are there any potential impediments to having an AAT team visit your facility (allergies, cultural/religious concerns, other)? |
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| Why are you seeking to add AAT to your client services at this time?: |
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| What types of AAT activities would your clients most benefit from (one on one interactions, group interactions, watching tricks, brushing, having dog in lap, having dog on bed, playing fetch games, PT assistance, other)? |
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| What other information might best help us match a team to your needs? |
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