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Great and Small Dog Training
Hi there, please fill out and submit this form to confirm your booking for a behaviour modification programme.
31
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1
Name
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First Name
Last Name
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2
Dog's Name.
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3
Address
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Street Address
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State / Province
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Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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4
Phone Number
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5
Phone Number
Please add a second phone number if you have one.
Area Code
Phone Number
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6
Email Address
example@example.com
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7
Please select your preferred contact method
*
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Phone call
Email
Text
Any
Phone call
Email
Text
Any
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8
Dog's Breed
*
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9
Dog's Age
*
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10
Dog's Sex
*
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Female Spayed
Female Unspayed
Male Chemically Castrated
Male Surgically Castrated
Mate Uncastrated
Female Spayed
Female Unspayed
Male Chemically Castrated
Male Surgically Castrated
Mate Uncastrated
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11
Vet Practice Used
*
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12
Vet Practice Phone Number
*
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13
Does your dog have any medical conditions (either prior or existing) that I would need to be aware of or take into consideration?
*
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Please include any food allergies or intolerances.
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14
Has your dog seen a vet for a full general health check within the last 6 months?
*
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Please note that I
strongly
advise that all dogs have seen a vet for a full, comprehensive health check before I arrange a behavioural consultation with you. This is because many behavioural problems can be linked to an underlying health problem or condition, therefore it is highly beneficial to do our best to rule out any possible health conditions or start any recommended treatments before beginning behavioural modification.
YES
NO
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15
Please detail why you are looking for a behavioural consultation and list any problems that you are hoping to address.
*
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Please provide as much detail as you can, include the context that the behaviour occurs in, your dogs body language and if they have ever caused any injuries.
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16
Does your dog have any other behaviour problems that I need to aware of?
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17
Please indicate the best day/s for your initial behavioural consultation.
*
This field is required.
I will do my best to accommodate your preferred days, however there might be a longer wait for weekend appointments. Behaviour consultations last between 2 - 3 hours. During the session I will gather a full history on your dog, discuss in depth the behaviour problems and form a behaviour modification and training plan for your dog, as well as - where suitable - a practical training session with your dog.
Wednesday
Thursday
Friday
Saturday
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18
Please indicate type of parking available
In some cases, clients may be asked to provide a visitors permit or cover the cost of pay and display parking
Free parking
Pay and Display
Permit parking only
Free parking
Pay and Display
Permit parking only
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19
Have you ever previously consulted a behaviourist for any reason?
*
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YES
NO
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20
If YES, please provide details, including the reason why behaviourist was consulted and any advice given.
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21
Has your dog ever shown reactive, or aggressive, behaviours towards any of the following? - Including; barking, lunging, growling, showing teeth, snapping and biting.
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Please select all that apply.
You or a family member
Other people
Other dogs
Never displayed reactive behaviours
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22
If YES, please provide details, including the behaviours shown and context they have been seen.
If your dog has bitten, please simply state BITE and provide more detail int he following section.
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23
Has your dog ever bitten or made contact with a person or a dog?
*
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YES
NO
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24
If YES, please select the relevant boxes to describe the incident/s.
To clarify, "multiple bites" refers to multiple bites in ONE single incident.
Muzzle punch (made contact with mouth closed, may leave a bruise)
Bite, leaving a mark or bruise, but DIDN'T break the skin
Bite, breaking the skin in one place, but NOT causing a deep wound.
Bite, breaking the skin in more than one place
Bite, leaving a SINGLE deep puncture or wound
Bite, leaving MULTIPLE deep punctures or wounds
Multiple bites, leaving marks or bruises, but NOT breaking the skin
Multiple bites, breaking the skin in several places, but NOT leaving a deep wound
Multiple bites, leaving ONE or MORE punctures or deep wounds.
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25
Please provide as much detail as possible for EACH incident, including context and any behaviours seen.
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26
Are there any safety considerations I need to be aware of?
*
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EG: a child in the house, another dog that is being affected by the problem behaviour/s
YES
NO
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27
If YES, please provide details.
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28
Is your dog subject to any court orders or police investigations? Or have the police been involved in an incident regarding your dog?
*
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YES
NO
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29
If YES, please provide as much detail as possible.
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30
Has your dog received any previous training or attending training classes?
*
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YES
NO
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31
If YES, please provide details including the type of training used.
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