Behavior History Form

Chronology of the Behavior Problem
What are the main behavior problems? *
How frequently are the main problem occurring? (how many times daily, weekly, or monthly) *
When did you first notice the main problems?
(ie, immediately after getting the dog, three months into having them, two years ago, last week, etc)
Additional Problems (please list)
How frequently are the other problems occurring?
When did it first become a serious concern?
(or just a concern, if it is not serious)
In what general circumstances do the behaviors occur?
Has the problem changed in frequency and/or intensity? Please describe
Please describe the most significant incident in detail
Please describe the second most significant incident in detail
Please describe the third most significant incident in detail
Other significant incidents
What have you done so far to try to fix the problem?
How do you discipline your dog for this and other misbehavior?

Home Environment
Please list the people living in your home, other than yourself. If there are any children, please include their ages. *
Ages are only needed for children
Please describe any/all animals in the household, other than the patient. Include their name, species, breed, sex, neutered/intact, age obtained, age now, and the sequence in which they were obtained. *
How many times have you moved since acquiring your dog?

Haven't movedOnceTwiceThree times or more
How has your household (people or animals) changed since acquiring your dog?

Info about you
Do you as an individual learn best by seeing things (visual), hearing things (auditory), doing things (kinesthetic/hands on), and/or reading/writing things?
We are committed to doing our best to accommodate your individual needs. If there is anything you would like us to be aware of about you, please feel free to share. This may include any physical disabilities, chronic pain, neurodivergence (ADHD, autism, intellectual disabilities, bipolar disorder, obsessive compulsive disorder, social anxiety, sensory processing disorder, personality disorder, major depressive disorder, etc), or anything else that may be relevant. Please let us know if there are any general or specific ways we can best support you. This information is completely optional to share. We can also discuss this in person or via phone or text.
What amount of personal notes and pertinent reading material do you think you would realistically be able to review after our consultation & sessions?

None (no notes or written information)Bare minimum (1 page of notes in bullet points)Some (1-2 pages of notes in bullet points and a few documents between 1-6 pages in length)All of it (all notes & relevant material for your case)

Dog's Background
Why did you decide to get a dog?
Where did you get this dog?*

ShelterRescueBreederPet StoreFriend or family memberStray
Please provide detail about where you got the dog. (Name of Shelter, Rescue, or Breeder) *
If you met the dog's parents, please describe their behavior
Why did you choose this breed?
How many previous homes are you aware that the dog had, if any? Do you know why the dog was given up?
How many people are in the dog's inner circle? These are people who can come over to the home, interact with and pet the dog without issues.*
How many of these people did the dog first meet after the dog was 1 year old?
(applicable if the dog is over 1 year of age)
How does the dog usually interact with these familiar people?
How often do you have familiar people at your home? (per week, month, or year?)
How does the dog tend to interact with strangers? (inside your home, away from the home, on leash, etc? Children or adults?)*
How frequently do you have unfamiliar visitors at your home? (per week, month, or year?)*
How does the dog tend to interact with other animals? (dogs, cats, prey animals?)*

Diet and Feeding
Any known allergies?*
What do you feed your dog? Please be specific*
Has your dog's appetite:

IncreasedDecreasedNo change
How much do you feed?
Meal times
How do you feed your dog? Bowl, slow feeder bowl, puzzle toys, etc
How quickly does your dog finish their food?*

Immediately, as fast as they canImmediately, at a regular paceImmediately, at a slow paceWithin a few hoursFree feeds- bowl is always full
What is your dog's favorite treat? *

Medical History
Has your dog had or currently have any medical conditions or health issues? This includes ear, skin, sensory issues, changes in appetite and weight, lethargic behavior, seizures, surgeries, illnesses, etc. Please describe.*
Is your dog on any medication now, for this or other problems? If so, please list specific medication names, doses, and frequency. Please also list any heartworm prevention, flea and tick prevention, medicated shampoos, etc.
Has your dog been on medication in the past? If so, please describe.
Is your dog on any supplements? Vitamins, herbs, etc.
Is the dog up to date on their rabies vaccine?
Is the dog up to date on heartworm prevention?

YesNo
At what age was your dog spayed/neutered? If they are intact, why did you choose to keep them intact? *
Were there any behavioral changes after spaying/neutering?
If your dog is intact, have they ever been bred?

YesNoDon't know
Are you planning to breed?

YesNoDon't know

Compulsive Behavior Screen

Please fill out to the best of your ability
Please select any behaviors your dog performs

Light or Shadow Chasing/StaringLicking Surfaces - walls, glass, doors, floors, fabric, furnitureLicking Self ExcessivelyTail ChasingFlank SuckingWool/Blanket/Toy/Pillow SuckingFly Snapping (no fly present)Predatory chasing/pouncing at something that isn't there
Please describe the frequency and intensity of any of the behaviors you selected

Conclusion
Please choose the answer that best describes your situation*

I am only here out of curiosity - problem is not seriousI would like to change the problem, but it is not seriousThe problem is very serious and I would like to change it, but if it remains unchanged I'll keep my dogThe problem is very serious and I would like to change it, if it remains unchanged I will have my dog euthanized or give them up
What are your goals for your dog?*
What do you love about your dog?
Please add any other comments in the space below
If desired, please provide feedback about your experience completing this form (technical issues, repetitive questions, questions you didn't understand, etc)

Sliding Scale Payment

If adjusted payment is not needed, you may select Option A below and skip reading this page. This model is laid out by The Dog Behavior Institute. My Sidekick Training offers sliding scale payment to those who rescued their dog.
Eligibility Requirements

Sliding scale payment is available only to those who have rescued/adopted their dog. This includes those who:
- Adopted from a shelter or rescue group.
- Rescued as their dog a stray, and adopted after looking for an owner and completing legal stray hold.
- Adopted a puppy at no or very low cost from an accidental litter, whose parents were both spayed and neutered after the pregnancy.
- Adopted an adult dog from an individual who could no longer care for them, and have had the dog spayed/neutered.
- Purchased a dog from a breeder after being unfairly denied from adopting a dog from a shelter or rescue group.
Exclusions

Sliding scale payment is NOT available for those who purchased their dog. This includes those who:
- Purchased from an individual, pet store, or breeder.
- Purchased a puppy from an accidental litter, whose parents have not since been spayed and neutered, or if the status of the parents is unknown.
- Received a puppy as a gift, and the puppy’s parents have not since been spayed and neutered, or their status is unknown.
However, Work Trade (Option D) is still available if you did not rescue your dog.

How it works

Please note that sliding scale programming is not a simple “discount.” If you are able to pay for full-price services, please do - this is how we can ensure that our sliding scale options are available for those who need them. Please be mindful that if you purchase training at the lowest end of the scale when you can truthfully afford the higher ticket prices, you are limiting access to those who truly need the gift of financial flexibility. Being honest with yourself and your financial situation when engaging with sliding scale practices grows strong and sustainable communities. Additionally, when the trainer is paid fairly, we are able to invest more time and resources to lower cost offerings. Here are general guidelines about how I currently price my sliding scale and to help you determine where you fall on it. Please select from the following options (A, B, C, D)
The highest dollar cost (OPTION A) reflects the true cost of the service. It is the cost that the practitioner would charge all students in the absence of a sliding scale. This price is for you if you: Have access to financial security, Own property, Have personal savings, Would not traditionally qualify for sliding scale services. Are able to pay for "wants" and spend little time worried about securing necessities in your life.

I do not need to utilize the sliding scale, and/or do not qualify for it (Option A)
The middle cost (OPTION B) reflects the practitioner's acknowledgement that paying the full cost would prevent some folks from being able to attend, but who do not honestly find themselves reflected in either descriptions for the highest cost or the lowest. This price is for you if you: Are struggling to conquer debt or build savings or move away from paycheck to paycheck living AND Have access to steady income AND Are not spending most of your time thinking about meeting basic needs such as food, shelter, medical care, child care, etc. However, if you can ask others, such as family members, partners, or friends, for financial support, please consider using those personal resources before you use the resources of the sliding scale and limit opportunities for others. Option B (the middle tier) offers a 20-40% price reduction (Pay 80-60% of normal training cost)

I qualify for and need to utilize the middle tier of the sliding scale option (Option B)
The bottom cost (OPTION C) represents an honest acknowledgment by the practitioner that there are folks whose economic circumstances would prevent them from accessing dog training services if there was not a deliberate opportunity made for them to access services at a cost that is reflective of their economic realities. This price is for you if: You struggle to maintain access to needs such as health care, housing, food, child care AND/OR Are living paycheck to paycheck AND/OR Are in significant debt. You deserve a community that honors your price as an equal economic offering as the person who can pay the highest tier. Option C (the bottom tier) of the sliding scale option gives an 50-80% price reduction (pay 50-20% of normal training cost).

I qualify for and need to utilize the bottom tier of the sliding scale option (Option C)
Work Trade (OPTION D) This option is available to anyone who is not able to pay the full cost of training, whether the dog was rescued or purchased. Work Trade may include volunteer work at Detroit Animal Care and Control (washing dishes, prepping enrichment, cleaning, walking dogs, remote work), landscaping, and other options. Volunteering at DACC or another municipal shelter will put $20 per hour of validated volunteer hours (not including volunteer orientation) towards the training costs. For example, 13 volunteer hours will cover the cost of your consultation. Work Trade can be used to fully or partially compensate the trainer within the options listed above.

I would like to do Work Trade for all or part of my consultation and/or training program (Option D)

Training Agreement

Please carefully read the following before initialing or signing.
By initialing below, I am indicating that I understand and agree that I am being trained to train my dog(s), and that without full cooperation with the trainer, my dog(s)'s behavior will not change. I understand that all training is contingent upon my willingness to handle and work with my dog as explained by the trainer. I understand that My Sidekick Dog Training, LLC cannot make any guarantee regarding the outcome of any training/counseling program. I assume full responsibility for the dog’s behavior during and after the training/counseling program.

Clear
By initialing below, I am indicating that I understand and agree that I am being trained to train my dog(s), and that without 100% cooperation with the trainer, my dog(s)'s behavior will not change. I have read and understand that all training is contingent upon my willingness to handle and work with my dog as explained by the trainer. *

Clear
My Sidekick Dog Training, LLC cannot make any guarantee regarding the outcome of any training/counseling program. By initialing below, I assume full responsibility for the dog’s behavior during and after the training/counseling program*

Clear
To my knowledge, my dog has exhibited aggression (growling, barking, lunging, snapping, or biting) to people or other dogs*

YesNo
If you answered yes to the question above, please read the following paragraph and initial below. By initialing at the bottom of this paragraph, I acknowledge that my dog(s) may be aggressive or is aggressive. My Sidekick Dog Training, LLC has fully explained that since the outcome of any training/counseling program cannot be guaranteed and the aggressive behavior on the part of my dog(s) is or may become a risk to people and/or dogs, my decision to enroll in a training program is done solely and completely at my discretion with me taking 100% responsibility for any damage my dog(s) might cause to anyone during or after the training program. My Sidekick Dog Training, LLC does not promise to solve or curtail my dog’s aggressive behavior. I further agree to take all possible safety measures recommended by my trainer, including but not limited to: muzzling and leashing my dog(s) when off my property, securing the fence of my yard, and securing doors and windows of my home. I agree to not let my dog off-leash outside when not in a securely fenced area.

Clear
By initialing below I indicate that I as the owner/agent will be responsible for acquiring all necessary safety equipment that the trainer recommends for training the dog(s). In the event either party deems it necessary to employ legal counsel to protect its rights under this agreement, the prevailing party agrees to pay all expenses including, but not limited to costs and reasonable attorney’s fees.*

Clear
Would you like to allow the use of photo and video of your dog's behavior assessment and training on social media and the website?*

YesNoMaybe
Observation and Note Taking: My trainer may record a transcription of our sessions for meeting summaries and record keeping. I authorize Ash of My Sidekick Training, LLC to record audio from our sessions. This will not be shared with anyone. The data is encrypted for security. Additionally, as part of Ash's commitment to increasing Diversity, Equity, and Inclusion in the humane dog training industry, they provide free education to aspiring dog trainers who are Black, Indigenous, and other Persons of Color. By initialing below, I understand that any of my lessons may have 1-2 people shadowing my trainer. They are there to learn from the trainer by quietly observing and taking notes, and will not interfere with the training session.

Clear
By SIGNING MY NAME below, I as the legal owner/agent of the above-mentioned pet(s), having carefully read and fully understand this agreement, do hereby waive and release My Sidekick Dog Training, LLC from any and all liability of any nature. This includes any injury, death, sickness or damage my pet may suffer during or after any training program. I also agree to indemnify and hold harmless My Sidekick Dog Training, LLC from any and all claims due to damage the pet may cause to any family members of any third parties during or after training.*

Clear
By initialing below, I understand that My Sidekick Dog Training, LLC does not offer any free consultation or training services. The full cost for a 2 hour consultation is $264. The full cost for the training program options are as follows: 4 Lesson Program - $500, 6 Lesson Program - $720, 10 Lesson Program - $1,150, 16 Lesson Program - $1,760. There is a 20% discount for those who adopted their dog from a shelter or rescue. Additionally, those who rescued their dog may be eligible for the Sliding Scale Payment Options. The full amount is due in CASH at the time of the consultation. The training program that I choose is to be paid in full at the beginning of the first lesson of the program. This amount is to be paid in cash. If consultation is held virtually, the full amount can be paid via Cashapp: $mysidekicktraining or Venmo: @ashrose313. If the dog is fearful and/or has demonstrated growling, barking, lunging, snapping, or biting directed towards unfamiliar people, the consultation will be held at the trainer's yard in Detroit, or held virtually on Zoom. Subsequent lessons will be conducted in person at a location designated by the trainer. I understand that I may withdraw from training at any time, however, once training has begun; all fees are non-refundable. Any training program needs to be completed within 6 months of start date. Any outstanding lessons after 6 months will not be fulfilled. I understand that it is my responsibility to schedule my training sessions on My Sidekick Training's Calendly page. I understand that unless there is an emergency, there is a 48 hour cancellation policy and it is my responsibility to cancel appointments in accordance with this policy or they will account for sessions of the training program I am purchasing.*

Clear
Sliding Scale Payment Options - if adjusted payment is not needed, select Option A and skip reading this section. My Sidekick Training offers sliding scale payment based on a model laid out by The Dog Behavior Institute. Sliding scale payment is available only to those who have adopted their dog from a shelter or rescue, or those who rescued as their dog a stray and adopted after looking for the owner and completing legal stray hold. The following text was written by the DBI. Please note that sliding scale programming is not a simple “discount.” If you are able to pay for full-price services, please do - this is how we can ensure that our sliding scale options are available for those who need them. Here are general guidelines about how I currently price my sliding scale and to help you determine where you fall on it. The middle cost (OPTION B) reflects the practitioner's acknowledgement that paying the full cost would prevent some folks from being able to attend, but who do not honestly find themselves reflected in either descriptions for the highest cost or the lowest. This price is for you if you: Are struggling to conquer debt or build savings or move away from paycheck to paycheck living AND Have access to steady income AND Are not spending most of your time thinking about meeting basic needs such as food, shelter, medical care, child care, etc. However, if you can ask others, such as family members, partners, or friends, for financial support, please consider using those personal resources before you use the resources of the sliding scale and limit opportunities for others. Option B (the middle tier) offers a 20-40% price reduction (Pay 80-60% of normal training cost). The bottom cost (OPTION C) represents an honest acknowledgment by the practitioner that there are folks whose economic circumstances would prevent them from accessing dog training services if there was not a deliberate opportunity made for them to access services at a cost that is reflective of their economic realities. This price is for you if you: If you struggle to maintain access to needs such as health care, housing, food, child care AND/OR Are living paycheck to paycheck AND/OR Are in significant debt. You deserve a community that honors your price as an equal economic offering as the person who can pay the highest tier. Option C (the bottom tier) of the sliding scale option gives an 50-80% price reduction (pay 50-20% of normal training cost). Please be mindful that if you purchase a price at the lowest end of the scale when you can truthfully afford the higher ticket prices, you are limiting access to those who truly need the gift of financial flexibility. Being honest with yourself and your financial situation when engaging with sliding scale practices grows strong and sustainable communities... Additionally, when the trainer is paid fairly, we are able to invest more time and resources to free and lower cost offerings.

Option A - I do not need to utilize the sliding scale optionOption B - I need to utilize the middle tier of the sliding scale (20-40% price reduction)Option C - I need to utilize the bottom tier of the sliding scale option (50-80% price reduction)Option D - I would like to utilize the work trade option to compensate my trainer for all or part of the training program (Possible work trade options may include dog care, landscaping, carpentry, drywalling, painting, tiling, car maintenance, or volunteering at a shelter.)
The terms and conditions set forth in this agreement cannot be modified or changed in any way unless agreed to by both parties in writing. By initialing below I am indicating that I have read, fully understand and agree to all of the above contract terms. *

Clear
Today's Date

MonthDayYear
Date
Thank you for taking the time to complete the questionnaire and training agreement. It may be a good idea to click "save", and make sure you received the link in your email (check spam), or copying the link and saving it somewhere before clicking "submit", just in case there is an issue with the submission. After you submit the form, you will see a link to the page where you can select a time for your consultation. We really look forward to helping you with your dog!

Ash Davis, CBCC-KA, CPDT-KA | 313 444 5852 | mysidekicktraining@gmail.com
Should be Empty:

	Bark or Growl	Snarl/Bare Teeth	Snap	Bite	Avoid or Cower	Compliant, No Reaction, or Don't Know
Lift Dog
Push or pull off furniture
Approach when on furniture
Disturb while resting or sleeping
Approach while eating
Touch while eating
Take dog food away
Take human food away
Take away bone/ rawhide
Take away dog toy
Take away forbidden object
Approach when dog has object/toy/bone
Verbally punish
Physically punish
Speak to dog (normal tone)
Stare at dog
Bend over dog
Push on dog's shoulders or back
Enter room
Leave room
Reach toward dog
Leash restraint
Collar restraint
Scruff restraint
Put leash on or take off
Put collar on or take off
Bathe dog
Towel dog
Brush or groom dog
Dog at groomer's
Trim nails
Leash or collar correction
Response to "Sit" or "Down"
Dog at veterinary clinic
Unfamiliar adult enters house or yard
Unfamiliar child enters house or yard
Response to toddlers or babies
Dog in car
Unfamiliar adult approaches owner, dog on leash
Unfamiliar child approach owner, dog on leash
Dog in house, sees people outside
Response to other dogs while on leash
Response to other dogs while off leash
Dog in crate

Canine Behavior History and Training Agreement

Multiple dogs with behavior issues?

Tips for successful form submissions

Chronology of the Behavior Problem

Home Environment

Info about you

Dog's Background

Diet and Feeding

Dog's Routine

Dog's Training

Medical History

Compulsive Behavior Screen

Fear and Aggression Screen

Please indicate your dog's reaction to each of the listed scenarios. If their behavior has changed over time, please check all of the responses that you know have occurred at some point.

Interactions with people

Interactions with other animals

Conclusion

Sliding Scale Payment

Training Agreement