Pre-Adopt Questionnaire

PRE-ADOPT QUESTIONNAIRE
General
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email*
Are you 18 years or older?*

YesNo
How many adults live in the household?*
Please list all names of adult household members and relationship to applicant.*
Do any children live in the household?*

YesNo
Please list ages of children.*
Does anyone in your home have allergies to dogs?*

YesNo
How are the allergies managed or planned to be managed?*
Are you expecting a child or planning a family in the near future?*

YesNo
How many consecutive hours a day are you away from home?*

Under 22-66-9Over 9
Residence
Do you own or rent your home?*

OwnRent
Neighborhood setting*
Please indicate type of dwelling*
Do you have a homeowner's association?*

YesNo
Landlord name*

First NameLast Name
Property main address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Landlord phone number*
Landlord email*
Homeowner's association contact name*

First NameLast Name
Homeowner's association contact address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Homeowner's association contact phone*
Homeowner's association contact email*
Does your homeowners association allow animals?*

YesNo
Does it state in your lease that animals are allowed?*

YesNo
Are there any breed or weight restrictions?*

YesNo
Please explain any restrictions.*
Does your homeowner's insurance have any breed restrictions?*

YesNo
Please list any restrictions.*
Size of yard*
Is your yard fenced?*

YesNo
Does the fence completely enclose the yard?*

YesNo
Type of fence*
How tall is the fence*
If you do not have a fence or it does not enclose the yard, how do you plan to keep the dog safe?*
How close is your home to the nearest busy road or highway?*

My home is on a busy road1-2 blocksFew blocks to a half mileOver a mile
Are you aware of animal leash and license laws in your city?*

YesNo
Are you aware of animal limits (# of pets) in your city?*

YesNo
Are there any pets residing in the home that you do not own?*

YesNo
Type of animal*

DogCatSmall animal (rabbit, ferret, rat, etc.)BirdExoticsFarm/livestock
Current/Previous Animals
Have you adopted from Heading Home K9 before?*

YesNo
What was the name of the dog while in our program?*
Do you currently have any animals?*

YesNo
Type of animal*

DogCatSmall animal (rabbit, ferret, rat, etc.)BirdExoticsFarm/livestock
For current dog(s), please tell us about the dog, including name, breed, size, age, sex, if neutered/spayed, living conditions (indoor/outdoor), primarily dominant/submissive, and any other relevant details.*
Is your dog up to date on annual exam, vaccinations, annual heartworm test, and heartworm preventatives?*

YesNo
For current cat(s), please tell us about the cat, including name, breed, size, age, sex, if neutered/spayed, living conditions (indoor/outdoor), if declawed, and any other relevant details.*
Is your cat up to date on annual exam and vaccinations ?*

YesNo
Have you previously owned animals?*

YesNo
Please tell us about all previously owned pets (do NOT include childhood pets or pets you were not the primary care and financial owner for), including name, breed, how long the pet was owned, living conditions (indoors/outdoors), neutered/spayed, and where the pet is now. *
Vet clinic name*
Vet name*

First NameLast Name
Vet phone number*
Vet clinic email*
Pet owner name *

First NameLast Name
Please list name and species of your pets that have been seen at this clinic.*
To confirm your pet(s) are current on veterinary care, we will be reaching out to your listed veterinarian. Please call them prior to submitting this application to authorize the release of that information to us.

If we are unable to confirm veterinary records or your pet(s) are not up to date, we will not be able to continue processing your application.
Have you ever had to give up a pet?*

YesNo
Please describe the circumstances.*
Thinking Ahead
What is the name of the dog(s) you are applying?*
Please share characteristics most important to you while adding a new pet to your home.*
Under what circumstances would you consider giving up a dog?*

AllergiesSheddingBarking/vocalDiggingHigh energyDoesn't know any commandsEscape artistHousebreaking strugglesJumps on furnitureJumps on peopleKids ignored petMoving out of stateMoving to a new home that doesn't allow petsNew babyOver-protective/territorialPets don't get alongSeparation anxietyIt would be extremely rare for me to give up a petGrows too largeOther
Please describe in detail methods you would use to try and correct/improve undesirable behaviors for any options selected above.*
Would you be willing to seek professional help/training with undesirable behaviors?*

YesNo
Do you plan on attending obedience classes with a new dog?*

YesNo
How do you plan to train the dog? Please be specific.*
What will happen with the dog if you move or your housing type changes?*
How much exercise will the dog be given daily?*
How will the dog get its exercise? *
Where will the dog sleep?*
Where will the dog be kept when alone?*
Where will the dog primarily live?*

IndoorsOutdoors
Do you plan to use a crate?

YesNo
How will the crate be used?*
Will you use a heartworm preventative?*

YesNo
Will you use a flea and tick preventative?*

YesNo
References
We require one NON-FAMILY reference for every application who can speak to your ability to care for a dog.

Applications with a family reference or without complete references will not be processed.
Reference Name*
Relationship*
Length of time known*
Reference Phone Number*
Reference email*
Do you agree to return any adopted animal to Heading Home K9 if your circumstances change and you are no longer able to care for the animal?*

YesNo
I, the undersigned, attest that, to the best of my knowledge, the above information is accurate and complete at the time of signing. I understand that falsely provided information can mean that my application will be terminated and repossession of the dog may occur.
Name*

First NameLast Name
Thank you for your application. Please note that Heading Home K9 Rescue is unable to accept every application for adoption. We have specific criteria for each dog and believe that it is in the dog’s best interest to select each home with care. Applications are PROCESSED on a first come, first served basis, but are APPROVED based on what is best for the dog. We have set guidelines for application acceptance and we understand that your opinion may differ from ours. Thank you for understanding.
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PRE-ADOPT QUESTIONNAIRE

General

Residence

Current/Previous Animals

Thinking Ahead

References