CCI Client Questionnaire

Client Intake Form and Application

Please fill out the questions below so we may direct you to a training program to fit your dog.

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Cell Phone

cell phone

Your Email Address

example@example.com

Partners' Name and Email Address

example@example.com

Other Members of Household and Ages if Minors:

What training type are you interested in?

Choose one from drop down menu

Dog's Breed/Mix

Best guess is fine

Name of Dog

Sex of Dog?

Male Female

Age

Weight

Color

Neutered or Spayed?

Where was your obtained? Please name breeder or rescue/shelter if you know it.

How long have you had your dog?

Dog walker or daycare provider you use (if any):

Please List current or past medical problems or injuries. List any medications dog is currently taking.

Is your dog currently on flea/tick prevention? If so which one?

Is this dog currently on heartworm preventative? Which one?

Please list the food you are feeding your dog and how often. Include details about feeding routine such as where your dog eats, does your dog get excited, wait patiently, etc.

What are your dog training goals for your dog?

Has your dog had previous training? If so where and what did you learn?

Do you use a crate for your dog?

Yes No

How does your dog behave when in the crate?

How long is your dog home alone during the day?

How does your dog react when you leave the house or is home by himself/herself?

What kind of collar/harness/leash are you using currently?

Do you let your dog meet other dogs on walks or on leash? If so how does it go?

Does your dog meet other dogs off leash at a dog park, in a yard, or on walks? If so how does it go?

How does your dog react when people enter your home?

Is your dog scared of things, noises, people, or other animals? If so please describe.

Is your dog sensitive to any body parts being touched or handled? Is so please describe.

Is your dog possessive (growling, nipping, biting) of toys, food, objects, people, or other resources? If so describe when and to whom (dog or person).

Has your dog ever growled at any person? Is yes please describe.

Has your dog ever bitten a human? Is yes, please describe including the extent of injury and medical care needed (if applicable).

Has your dog ever bit or fought with another animal? If yes please describe.

Does your dog have any obsessive behaviors such as tail chasing, licking, grooming, barking? If yes please describe.

List any other issues you wish to be addressed by dog training (other than those listed above).

What are your dog's best qualities and what do you like about your dog?

I understand that I am responsible for ensuring my dog is up to date on his/her rabies vaccine prior to training. I affirm that any medical concerns or symptoms will be conveyed to the trainer prior to my dog's training date. I also understand that my dog will need a negative fecal test for giardiasis and worms within 14 days prior to my dog's first board and train program with Canine Counselor Inc. If I book a board and train program, I will make the needed arrangements with my veterinarian to get the fecal test completed. Any newly aquired dogs must be in the home with the dog guardian(s) for minimum of two weeks before the dog's first training program or lesson. This will allow time for the dog to acclimate and any illness to manifest.

I affirm