Dog Behavior Consultations Registration Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Do you have an appointment?*

YesNo

If so, when is your appointment?

Date

Time

:HourMinutesAM/PM Option

Name*

Gender*

Male NeuteredFemale SpayedMale UnalteredFemale Unaltered

Breed *

Age*

May I contact your vet?*

YesNo

Vet Name

Vet Clinic

Vet Phone

Area CodePhone Number

When was the date of your last vet visit?*

Date

Is your dog up-to-date on vaccines?*

YesNo

List any prior or current health issues:*

Where did you get your dog?*

How long have you had your dog?*

What do you know of your dog's background?*

How would you describe your dog's personality?*

Household Members*

	Name	Age	Gender	Relationship with Dog
Resident #1
Resident #2
Resident #3
Resident #4
Resident #5

Other Pets *

	Name	Age	Gender	Relationship with Dog
Pet #1
Pet #2
Pet #3
Pet #4

How would you describe your home?*

Busy, activeQuiet, calmMiddle of the roadOther

How does your dog react when strangers come over?*

Have there been any changes to the household? If so, describe and state when the change occurred (new roommate, new pet, redecorating, etc).*

Has your dog had any professional individual or group training?*

YesNo

If yes, where did you take your dog for training and which class(es) did you take?

How much time does your dog spend outside?*

Yes, free to roamYes, supervised outings (on leash/stroller/catio)No

Is outside time supervised or unsupervised?*

Where does your dog spend most of his/her time?*

Is there a specific time designated for daily play?*

YesNo

If so, when if your designated play time and how long do you play?

What are your dog's favorite toys and ways to play?*

How often do you walk your dog and for how long?*

What type of equipment do you use to walk your dog? (Ex: Retractable leash, long line, harness, prong collar, etc)*

Do you offer mental exercise?*

What do you feed your dog?*

Wet FoodDry FoodRaw Food

What brand of food do you feed?*

How often do you feed your dog?*

How is water offered to your dog? How often is water changed?*

Do you feed treats?*

YesNo

How often do you feed treats? What kind of treats do you feed?

Please list any dietary restrictions

Please list any supplements or medications your dog receives. How often does your cat receive these?

What is the problem behavior?*

How long have behavioral issues been occurring?*

How often does the behavior occur?*

What has been tried to correct the problematic behavior?*

Have any of the attempts to change the behavior helped or worsened the problems? Explain.*

Has your dog bitten anyone?*

YesNo

If yes, describe the bite circumstances. Be sure to include if the bite broke skin and if medical attention was needed.

What are your feelings on the problem behavior? Under what circumstances would you consider re-homing? Under what circumstance would you consider euthanasia?*

May we record your session, in part or in entirety?*

YesNo

What are your goals and expectations for changing your pet's behavior?

1 month from now:*

6 months from now:*

1 year from now:*

Preferred Payment Method*

If Venmo, what is your username?

*Cash and check payments are not accepted for virtual services.

Dog behavior consultations are $100/hr and will be charged upon completion of the consultation to assure accurate pricing for a shorter or longer session.

Do you prefer that Emily wear a mask?*

YesNo

Great and Small Animal Behavior and Training will endeavor to create as safe an environment as possible for the training/behavior modification of my dog and will offer only sound, safe, and responsible behavior and training instructions. However, to the extent that Great and Small Animal Behavior and Training is insured for any unintentional or negligent errors, omissions, or incorrect assertions, Great and Small Animal Behavior and Training will be responsible for any such acts or omissions, but only to the extent of such insurance. I have been told by Great and Small Animal Behavior and Training and understand the inherent risks of owning a dog, including but not limited to the risk of dog bites to myself or others. I represent and warrant that I have provided Great and Small Animal Behavior and Training with full and complete, accurate information regarding any bite history and similar incidents or hazardous tendencies of my dog, and that I will update that information if it changes. I understand that I am and will remain responsible for the actions of my dog at all times, and I hereby agree to indemnify, release, and hold harmless Great and Small Animal Behavior and Training of any and all claims, whether made by myself or any third party, of injury, expense, costs, or damages caused by my dog. I understand that the recommendation of any other product or service is not a guarantee of my satisfaction with that product or service. This contract, together with language expressly incorporated into it in writing, is the full and complete agreement between me and Great and Small Animal Behavior and Training. A complete and accurate copy of this contract is as valid as the original. This contract is made valid by in-person signatures, electronically signed signatures, or upon receipt of a signed, scanned copy by email.

Payment Policy:
I agree to provide complete payment of the previously established service fee upon completion of the behavior service. Great and Small Animal Behavior and Training keeps your information confidential. I understand that changing an animal's behavior takes time and commitment. Due to the nature of this work, results cannot be guaranteed and there are no refunds.

Cancellation Policy:
I understand that Great and Small Animal Behavior and Training must receive at least one hour’s notice prior to cancellation. Should Great and Small need to cancel or reschedule, they will notify me at least one hour prior. Any prior payment shall be reimbursed or credited in case of cancellation.

Signature*

Dog Behavior Consultation Questionnaire

Dog Information

Household Information

Activity and Training

Diet Information

Problem Behavior

Liability Waiver and Policies