Pet Communication Questionnaire Form

Pet Communication Questionnaire

Please fill out this information form for each animal that Cyndi will be communicating with.
Your Name *

First Name Last Name
E-mail *
Phone Number *

Area Code Phone Number
Is this an emergency?

Yes
Information about the animal I will be communicating with:
Your Pet's Name, Nickname, or what you call them *
Age
Species & Breed *
Gender *

Male (intact) Female (intact) Spayed Female Neutered Male
What is the main reason you would would like me to communication with your pet?

Please give me a list of the questions you want me to ask or what you would like me to communicate with your pet about.

Please write these questions as if you are writing them to your pet.

Communicate like you would communicate with a 2 year old. Very simple language.

If you feel like I need to know any background information to help clarify and communicate with your pet, then give me that as well.
Main reason *
Background
Your Message
Please list your 10 questions: *
1.
2.
3.
4.
5.
6.
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8.
9.
10.
Please give me the names of each person in the house and name of all other animals in the house so I can refer to them if needed. I need to know the names that your pet would know you as. Do you refer to yourself as Mom or your name. For the other people and animals in the house, use their name, or nickname. Whichever one you use most often around the pet I am communicating with. (e.g. Name is Lynn, but you call her Mom, then refer to as Mom. Dogs name is Norman but you call him Bubba).
Refer to You as *
People in Home
Other Animals (Name,Gender, Species)
Additional Details: (optional)

In certain circumstances, it's helps me to have a little background information so that I can navigate the conversation and ask clarifying questions that you may not know to ask.

For the following situations, please expand the section and give me more details.

All of the details are not required. I can simply ask the questions you want me to ask and give you the answer I receive. However, these details enhance my ability to resolve the issue and enhance the session, so you can get as much information as possible.

If this is regarding a health issue:
Please give me as much information as you can so I can talk to your pet like a dr. would talk to a child about how they feel. (e.g. let me know if your pet is not eating, is limping, or licking themselves, has been vomiting or has diarrhea, etc.)

Include any medical diagnosis like cancer or liver disease.
Health Details, Symptoms
Diagnosis

If this is regarding two pets not getting along:
Please give me a brief history of both pets. Have they been fighting; any bites, severity, who started it, etc. Tell me which one is older, which one was in the house first, if there are other pets, tell me all of their names, male or female, age, if spayed or neutered or intact and who you think is leader. This helps me to understand the dynamics of a multi-pet household so I can communicate appropriately about the other pets.
Other pet(s) - (Name, age, gender, neutered?)
Pack Dynamics
Order of when pets came into your home
History of problem

If this is regarding a behavioral issue:
(e.g. peeing in the house, barking at people, separation anxiety, etc), then please tell me how long this behavior has been going on and when it started. And any history you think I should know in order to understand what your pet may be telling me or showing me. This helps keep me from misinterpreting images or explanations your pet may be telling me.
Behavioral Details

Attach Picture
Please attach at least one picture of the animal with which I will be communicating. If there are more than one animals involved, attach picture of each one. If you refer to any other animals in your questions, please attach a picture of them as well. Please include the name of the animal in the filename.

Make sure the picture is color and without any people in it. It's best if I can see their face, specifically their eyes.
Attach picture *

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