National Capital Therapy Dogs, Inc.
P.O. Box 234
Highland, Maryland 20777
301-585-NCTD (6283)
http://www.nctdinc.org
E-mail: info@nctdinc.org

NCTD Facility Profile

This form is intended for facilities that wish to begin an AAA/AAT program with NCTD. This is not an agreement or contract. It is simply a means for NCTD to gather information about your facility and it's needs.

Please complete and submit this form as accurately as possible so we can better get to know your facility and it's particular needs. If you would prefer, you can print this page, fill it out by hand (please PRINT the information clearly), and mail it to:

John Burrows
Director of Facilities
National Capital Therapy Dogs, Inc.
13905 Turkey Foot Road, N.
Potomac, MD 20878

Note that there are not necessarily any right or wrong answers. Based on the specifics of your facility, we may have different team/coordination requirements.

General Information

How did you find out about us? (Check all that apply.)
Website Brochure Referral Client Magazine/Newspaper Article
Other: (specify)

Points of Contact (POCs)

Primary POC Information:

Name:
Phone Number:
Fax Number:
E-mail Address:

Alternate POC Information:

Name:
Phone Number:
Fax Number:
E-mail Address:

Other POC Information:

Facility Information

Name:
Address:
Phone Number:
Fax Number:
E-mail Address:
Web Site:

Type of Facility: (check all that apply)
Hospital   Long-Term Care   Assisted Living   School
Rehabilitation Center   Mental Health   Pediatric Care
Hospice   Nursing Home
Other (please specify):

Facility Logistics:

Number of Buildings (we'll be visiting):
Number of Floors/Units (we'll be visiting):
Will we need to use elevators?:	Yes No
Will we need to use stairs?:	Yes No
If yes, how many flights?:
Where will we park?:
If other, specify:
Is Parking Free?:	Yes No
If no, what is the parking fee?:
Special Parking Requirements (validation, security checks, etc.) :
Where is the "potty" area for the animals?

Other Facility Information:

Staff Information

Anticipated Number of Staff per Visit:
Anticipated Level of Staff Interaction:

What type of staff will teams work with? (check all that apply)
Receptionist   Occupational Therapist   Recreational Therapist
Physical Therapist   Nursing Staff   Medical Doctor
Physician Assistant   Teacher   Administrative
Other (specify):

Additional Information: (check all that apply)
Staff will provide list of clients to volunteers.
Volunteers will visit with clients with minimal/no staff accompanying.
Staff will be in the general area (e.g., on the floor/unit).
Staff will always be present with teams.
Staff will prepare and provide client goals to each team.
Staff will direct interactions with clients to accomplish goals.
Staff will attend/direct pre-visit meeting for discussion.
Staff will attend/direct post-visit meeting for discussion.
Staff are interested in registering as Delta Society Pet Partners and taking training courses.
Staff are interested in NCTD presenting an in-service seminar/demonstration.

Other Staff-Related Information:

Other Groups/Teams

Is there a visiting animal group/team in your facility presently? Yes No
If yes, please answer the below questions.

Group Name:
Contact Name:
Contact Phone:
We Want NCTD to Visit:	In addition to this group/team Instead of this group/team
Why do you want NCTD to Visit?

Other Group/Team-Related Information:

Client Information

Age Groups: (Check all that apply)
Infants   Children   Teens   Young Adults
Adults   Seniors

Client Conditions: (Check all that apply)
Confusion   Developmental Disorders   Physical Disabilities
Difficulty Speaking   Difficulty Hearing   Difficulty Seeing
Psychiatric Disorders   Well Elders   Frail Elders
Immune Suppressed Systems   Reading Limitations
Other (specify):

Anticipated Number of Clients Per Visit:

Clients will be Screened Prior to Visits for: (Check all that apply)
Animal Allergies   Health Status   Interest
Fear of Animals   Infection Control (Human/Animal)

Other Client Information:

Visit Schedule

Anticipated Visit Schedule (check all that apply):
Weekdays   Weekends
Morning   Early Afternoon   Late Afternoon   Evening

Anticipated Number of Visits per Month:
Anticipated Visit Length: (Most NCTD visits are 1 hour.)

In addition to the visit, we request (check all that apply):
Pre-visit meetings   Post-visit meetings

Other Visit Information:

Volunteer Logistics

Anticipated Number of Teams per Visit:

Volunteer Requirements: (check all that apply)
Volunteers need to attend an orientation with volunteer office.
Volunteers need to obtain facility identification card/badge.
Volunteers need to meet specific health requirements (e.g., TB test).
Volunteers need to obtain a parking permit.
Volunteers need to sign in/out before/after each visit.
Volunteers need to provide copy of animal health records.
Volunteers need to provide copy of team certification information.

If any items above are checked, please specify details:

Other Volunteer Information:

Animal-Assisted Activities (AAA)/Animal-Assisted Therapy (AAT) Program Information

Where will we meet prior to each visit?:
If we meet in a different building from where we visit, how will teams move between buildings?

Program Information: (check all that apply)
Existing AAA/AAT guidelines have been defined/documented at facility.
Facility interested in obtaining a copy of Delta Society Standards of Practice for AAA/AAT Programs Manual.

Visit Environment: (check all that apply)
Bed Visits   Day Room   Lobby   Activity Room   Hallway
Locked Unit   Intensive Care Unit (ICU)   Waiting Room   Classroom
Library   Outside
Other (specify):

Volunteer Team/Client Ratio:

Visit Activities: (check all that apply)
Hugs/Kisses   Brushing/Grooming   Walking   Retrieving
Obedience   Tricks   Reading   Sharing Pictures
Taking Pictures   Other (specify):

AAA/AAT Goals: (check all that apply)
Mental Stimulation   Fine Motor Skills   Gross Motor Skills
Entertainment   Memory   Socialization   Speech
Reading   Other (specify):

Are Cameras Allowed?   Yes   Polaroid Only   No
Camera/Recording Device Rules/Regulations:

Other Program Information:

Other

Anything Else NCTD Needs to Know: