Head and Heart Training: Consultation Intake Form

Head and Heart Training: Consultation Intake Form

Please fill out the following form if you are interested in our services and we will get back to you within two business days. All information is kept confidential. Please note that our business hours are Tuesday through Saturday 9-5.
Section 1 - Guardian information
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Availability for training sessions (indicate which days of the week and times you are most available for scheduling).
What kind of Consultation are you booking?

Behavioral ConsultationAggression Consultation
How did you find out about Head and Heart Training?
I prefer the trainer to wear a mask while indoors

YesNo
List all members of your household (name, age, pronouns)
Please list any accessibility needs that you would like me to be aware of for any members of your household.
List any other pets in the household
Section 2 - Canine Information
Dogs name; age; breed; sex
Dog approximate size (in pounds or kilos)
Dog's origin (adopted, from breeder)
How long have you had your dog for?
Section 3 - Medical Information
My dog is spayed/neutered

YesNo
When is the last time your dog had a vet checkup?
List any medical Issues your dog has, or has had historically
Please any medications or supplements that your dog is on.
Please list any food allergies or sensitivities.
Have there been any recent changes to your dog’s health?
Section 4 - Behavioral History
What issues are you looking for help with?
How does your dog respond to being left alone?
When is the last time you had a new person in the home, and how did your dog respond?
Please describe briefly each time your dog ever growled at, lunged at, bitten, or acted aggressively towards any person, and how long ago the incident took place.
Please describe the extent of the injuries to people or animals that have been bitten by your dog (bruising, shallow vs deep punctures, multiple bite marks or just one bite, has your dog ever killed another animal?)
Do you feel like there has been a recent and sudden change in your dog’s temperament or personality?
Do your dog’s aggressive behaviors occur during touch, petting, or body handling?
Client-Trainer agreement and Waiver

By signing below, you are agreeing with the terms of the following agreement. This agreement is made between the undersigned Client and Kathleen Higgins (“Trainer”), of Head and Heart Training, concerning the above-named Dog (“The Dog”).
The Client agrees to the following conditions:

•To follow the trainer’s instructions without modification regarding any and all training and treatment of the Dog.

• The Client grants Head and Heart Training and Kathleen Higgins (the "Trainer") permission to use photographs and/or video recordings of the Dog taken during training sessions for advertising, promotional, and educational purposes. This includes, but is not limited to, use in newsletters, social media, website content, and other marketing materials to showcase training techniques and success stories. The Client understands that no identifying information beyond the Dog's name and breed will be used without explicit consent. The Client waives any right to compensation or royalties arising from the use of these images or recordings. If the Client wishes to revoke this permission at any time, they must provide written notice to the Trainer.

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•To provide truthful information about the number and severity of all past bites, air snaps, or other instances of aggression that have occurred with the dog to the trainer prior to using any services to the best of their abilities.

•There is a zero tolerance policy for disrespectful or abusive behavior towards the trainer or between household members during training sessions.

•Pre-payment, in accordance with the price listings from https://www.headandhearttraining.com/training or the amount agreed upon in writing, is required to book and confirm your reservation. Nothing is confirmed unless paid in full.

•Consultations, training Sessions and packages are non-refundable and a credit of unused sessions will remain on file for 6 months, after which remaining credit is forfeited unless we have agreed otherwise in writing.

•Client acknowledges that all training sessions with the Dog carry inherent risks. Client hereby releases and discharges Trainer from any and all liability, claims, or damages arising from the Dog's actions during or after training sessions, including but not limited to property damage, bites, or injuries to any person or animal, or the Dog itself. Client assumes full financial and legal responsibility for any and all consequences resulting from the Dog's behavior.

The Trainer will provide:

• An honest and scientifically-informed discussion about what realistic goals are attainable for your dog and family through a behavior modification program. This may include discussion about medication, rehoming or behavioral euthanasia.

• Professional training, as certified by the Victoria Stillwell Academy Professional dog trainer course and SPCA AnimalKind program.

• Ample availability to book all sessions before their six month expiry date.

• A consultation report to be provided within 7 days of the completion of the consultation, and written notes and instructions to be provided within 7 days of all training coaching sessions.

• Ongoing chat support through whatsapp or email Tuesdays through Saturday 9am-5pm over the duration of the training package.

• The Trainer guarantees only professional training guidance and cannot guarantee behavior or results in individual dogs.

• The Trainer reserves the right to discontinue training without refund if the dog or client is considered unsafe to work with, or if the client fails to adhere to the conditions of this contract.
Client Signature

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Head and Heart Training: Consultation Intake Form

Section 1 - Guardian information

Section 2 - Canine Information

Section 3 - Medical Information

Section 4 - Behavioral History

Client-Trainer agreement and Waiver