Become a Recipient

Assistance can range from paying for veterinarian care, to paying adoption fees and transporting the pet for vet checkups.  Pets on Wheels CT strives to improve the lives of people whose mental or physical health would benefit from owning a pet but need assistance.  The organization works through a referral network of health care professionals and faith-based organizations to place suitable homeless animals with people who will benefit from the human-animal bond.

To request assistance for yourself or a client you are referring, please fill out the form below.  If you are applying for yourself, please include the name and phone number of a referring professional.  If you are referring a client, please include your name and phone number in the Referring Professional section.

We provide assistance to individuals in need to adopt a new pet.  If you are seeking financial assistance for a pet you already own, click here to view a list of organizations that may be able to help.

Contact Information

First and Last Name *

Age *

Phone Number *

Email Address

How do you prefer to be contacted? *

Phone

Email

Street Address *

City *

State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code *

How did you hear about us? * Referring professional (social worker, doctor, etc.) Radio Television Flyer Event booth Presentation by POW CT volunteer Social Media Website Other

If other, please describe

Referring Professional

Referrer's Name *

Referrer's Phone Number *

Referrer's Email Address (if known)

Have you signed a HIPAA form allowing your provider to discuss your case with Pets on Wheels of CT? * Yes No

Please sign a HIPAA authorization form with your provider. You can submit this application now, but the application process cannot continue until your provider has your permission to discuss your case with Pets on Wheels of CT. (Some referring professionals will not require a signed HIPAA form.)

Personal Reference

Reference's Name *

Reference's Phone Number *

Reference's Email Address (if known)

General

What type of assistance are you requesting? *

Adoption Fees

Veterinary Care (*Must be preauthorized by Pets on Wheels)

Transportation to Veterinary Appointment

Please describe the age and gender of members of your household *

Do you currently own a pet? * Yes No

Have you owned a pet before? * Yes No

Have you personally been responsible for the care of a pet? (whether or not you were the owner) * Yes No

Please describe any pets you've owned or cared for, and your level of experience *

Would you prefer: * Cat Dog No preference

Additional Information for Dog Ownership

Do you live in a: * House Condo Apartment

Would there be anything preventing you from walking a dog on a daily basis? *