A new professional has come on the scene: health and human service providers who incorporate animals into their practice. Delta has responded to this by developing a resource database and network of animal-assisted therapy (AAT) professionals. In its early stages, the database will be used to gather and distribute reliable information about people utilizing animals in their professional practice.
If you are already providing AAT as a licensed professional, Delta Society would like to include you in our database. Please complete the form below.
If you have any questions, please send an email message to petpartners@deltasociety.org or (425) 679-5506.
Mr./Mrs./Ms./Dr.
Name ____________________________________________________________
Professional Title ____________________________________________________
Address to be Published ______________________________________________
_________________________________________________________________
_________________________________________________________________
Phone to be Published ________________________________________________
FAX to be Published _________________________________________________
E-Mail Address to be Published ________________________________________
Professional Credentials: ______________________________________________
Professional liability insurance coverage through: ____________________________
I am a Pet Partner:
- _____ Yes.
- _____ No.
Field of Practice:
- _____ Education.
- _____ Mental Health/Counseling/Therapy.
- _____ Nursing.
- _____ Occupational Therapy.
- _____ Physical Therapy.
- _____ Recreation Therapy.
- _____ Other: __________________________________________________
Age Groups Served:
- _____ Children.
- _____ Adolescents.
- _____ Adults.
- _____ Seniors.
- _____ Other: __________________________________________________
Population(s) You Serve:
- _____ Abuse Survivors.
- _____ Alzheimer's/Dementia.
- _____ Criminal Offenders.
- _____ Developmental Disabilities.
- _____ Emotional Disabilities.
- _____ Homeless Populations.
- _____ Hospice.
- _____ Mental Illness.
- _____ Neurological Disorders.
- _____ Physical Disabilities/Injuries.
- _____ Other: __________________________________________________
Type of Facility in Which You Work:
- _____ Private Practice.
- _____ Acute Care Hospital.
- _____ Assisted Living/Intermediate Care.
- _____ Corrections.
- _____ Day Treatment/Group Home.
- _____ Hospice.
- _____ Psychiatric Facility.
- _____ Rehabilitation Facility.
- _____ School.
- _____ Shelter.
- _____ Skilled Nursing Facility.
- _____ Other: __________________________________________________
Types of Animals With Which You Work:
- _____ Dogs.
- _____ Cats.
- _____ Birds.
- _____ Rabbits/Cavys.
- _____ Wildlife: _________________________________________________
- _____ Other: __________________________________________________
I authorize Delta Society to release my name, address, and telephone number, as well as the area of my practice, to individuals and organizations as a professionally practicing AAA/T resource.
Signature ________________________________________________
Date _____________________________
Printed Name ____________________________________________
Return To:
Cora Bates
Delta Society
875 124th Ave NE, Ste 101
Bellevue, WA 98005
aat@deltasociety.org
