CCI Client Questionnaire

Canine Counselor Inc.

Client Intake Form and Application

Please fill out the questions below so we may direct you to a training program to fit your dog. Please check our prices BEFORE completing this form.

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

CELL Phone (PLEASE TYPE CAREFULLY, WE RECEIVE LOTS OF TYPOS ON NUMBERS)*

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? Please read our website BEFORE selecting.

Choose one from drop down menu

How did you hear about us?

Dog's Breed/Mix*

Best guess is fine

Name of Dog*

Sex of Dog?*

MaleFemale

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?*

YesNo

How does your dog behave when in the crate?

Is your dog allowed on the furniture? If so when?*

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

This Training Contract (“Contract”) is between Canine Counselor, Inc (CCI) and the Owner of the dog or Trainer of the dog being placed in the kennel or into training (“Owner”). CCI agrees to train the above-described dog. Owner/Trainer shall, upon execution of this Contract, deposit one-half (1/2) of the estimated cost of the board and train program prior to the start of training. Payment for private lessons is due upon completion. Owner/Trainer understands that the actual cost of training may vary significantly from the estimated cost, because the estimate is only based upon a preliminary evaluation. Failure by the Owner/Trainer to cancel a scheduled lesson twenty-four (24) hours in advance will result in a full day charge. Additional payments shall be made by Owner/Trainer to CCI upon completion of training or when requested by CCI. If Owner/Trainer fails to make any payment when due, CCI may charge 1 1/2% per month interest on any outstanding balance until paid in full plus any costs of collection (including attorney fees) if collection is required. Any future training provided by CCI to Owner/Trainer shall be provided under the terms of this Contract and at the current daily rates charged at the time of such training. Owner/Trainer has been advised that dogs have different degrees of ability to absorb and retain training. Every dog’s training requirements are different and CCI will make a good faith effort to train Owner’s/Trainer's dog based upon the capabilities of the dog. Results are dependent upon the owner’s commitment to the training plan, therefore, CCI does not guarantee the results of the training. Owner/Trainer represents that all inoculations are current. Owner/trainer represents that the dog has not been exposed to Rabies, Distemper, Bordetella, or Parvo within a thirty-day period prior to boarding. Owner/Trainer will provide proof of current vaccinations including Kennel Cough (bordetella). If dog becomes ill or if the state of the animal’s health otherwise requires professional attention, CCI, at its sole discretion, may engage the services of a veterinarian or administer medicine or give other requisite attention to the dog and the expenses therefor shall be paid by Owner/Trainer. Owner/Trainer hereby releases, to the extent allowable by law, CCI, its trainers, employees, agents, shareholders, officers and directors from any liability or responsibility if the dog causes harm to itself, the Owner/Trainer or the Owner’s/Trainer's family, or to other persons, animals or property. Owner/Trainer agrees to hold harmless, to defend and to indemnify CCI, its trainers, employees, agents, shareholders, officers and directors from any and all claims, demands, actions, causes of action, rights, obligations, liabilities, damages, costs, expenses, and other losses of every kind and nature, including any third party claims and any harm or damage of any nature or kind caused by the dog or caused by the Owner’s/Trainer's care or handling of the dog, including but not limited to: (a) the dog biting any person or animal, (b) the dog causing damage to property, or (c) the dog running away or harming itself. In no event shall CCI’s liability to Owner/Trainer exceed the amounts paid and/or owed to CCI by Owner/Trainer for training, boarding, and other miscellaneous fees. This Contract contains the entire agreement between the parties. All terms and conditions of this Contract shall be binding on the heirs, administrators, personal representatives, successors and assigns of the Owner/Trainer and Canine Counselor, Inc. In any litigation arising out of or relating to this Contract or the breach thereof, the prevailing party shall be entitled to recover reasonable attorney fees and costs. Owner/Trainer agrees to all terms and conditions as stated in this contract. It is further understood and agreed that no warranty or representation has been made or will be made with respect to said training except as set forth herein.*

I affirm

Signature*