New Client Information Form

New Client Information Form

www.fearfuldogsproject.org
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
example@example.com
Mobile Phone Number*

Area CodePhone Number
Other Phone Number*

Area CodePhone Number
Emergency Contact Name & Phone #*
Names & ages of other people in the dog's home and/or who care for or access the dog*
Dog's Name, gender, age, birthday, & breed*
Dog's Color/ Markings and weight/size*
When did the dog join you?*
Is the dog sterilized?*
If sterilized, when & by which vet?*
Any other dogs in the home? If so, please state age, gender, breed, sterilization, and vaccination status.*
What if any foods or other items is the dog allergic to?*
What kind and quantity of food does your dog eat for meals, and how often?*
How often does your dog get treats, and what kind?*
Have there been any recent changes in health or any recent injuries?*
When was the dog's last vet visit, and for what?*
Dog's Health:*

PoorFairGoodExcellentOther
When was the dog's last rabies vaccination, and by what vet? 3 year or 1 year vaccine?*
Name & ph# of vet
When were the dog's last parvo & distemper vaccinations (and any others)?*
What medications is the dog on currently and/or what medications has the dog had within the six months or so? *
Has the dog ever been prescribed (whether taken or not) psychopharmaceutical medication? If so, which meds and for what conditions?*
Have psychopharmaceutical medications ever been suggested or requested for your dog by you or by anyone else? If so, what was the response?*
Has the dog had any surgeries, illnesses, or other treatments in the past year or two?*
Do you give permission for your dog's veterinarians to provide vet records and notes to us?*

YesNo
Please provide all of dog's vets' names and contact info.*
If you answered no to the above, please provide us with a copy of current vaccination records and give your vets permission to confirm them with us via telephone.
Enter vet's name & telephone number above.
Where did you obtain this dog?*

Shelter adoptionRescue adoptionFriend or FamilyCraigslist, Facebook, newspaper, or other adI found the dog (lost dog/stray/wandering)BreederPet storeThis dog is from a litter of another dog of mine.Other
Did the dog live with other owners, fosters, or anyone else before you? Please give all details possible.*
Do you know what, if any, type of training (or handling) others used with the dog before you obtained the dog? Please provide details if known.*
What types of handling & training methods & equipment have you used with the dog? Please elaborate in the "other" area.*

verbal corrections (e.g., "no", yelling, warning, etc)physical correction (e.g., leash pops, squirting, other--please specify)positive reinforcement (what do you use for the reinforcer?)prong collar/tightening collarsshock collar/vibrating collars"dominance"Other
Please elaborate with details on your choices above. *
So far, how do you let your dog know what behavior you want and how have you addressed undesired behavior?*
Have you taken the dog to any training previously? If so, when, for how long, and with whom (please provide name/business name)*
Has your dog ever been confiscated or quarantined by animal control, or otherwise involved with animal control?*
Please explain details.
Please describe the details of any behavior problems you or anyone else has experienced with the dog.*
Use 'word pictures' to help us envision what happened.
Have any behaviors of concern started just recently? If no, when did they begin?*
Has your dog ever bitten, tried to bite, lunged at, growled, or behaved aggressively toward any person or animal? If yes, please state which of these and why you think it happened.*
Use 'word pictures' to help us envision what happened.
Please describe the events leading up to any bites, attempted bites, lunging, avoidance, or other behavioral concerns you have regarding the dog.*
Again, use 'word pictures' to help us envision what happened.
Has the dog ever cowered, trembled, 'frozen,' attempted to avoid you or others, or seemed oddly uncomfortable? If yes, please state which of these*
Please give details
Have there been any sudden or recent changes in the dog's life / environment?*
How does your dog spend her/his days and evenings?*
How many hours per day/night without you?*
Where does s/he sleep (e.g., bedroom, couch, bed, crate, garage, kitchen, laundry room, yard, etc)*
Is the dog ever crated, tethered, or otherwise confined? If so, for how long per day/night?*
What does the dog most enjoy, and how often does the dog do that?*
What do you most enjoy about the dog?*
If you had to pick just one thing to change about your dog, what would it be?*
If your dog had to pick one thing to change about you, what do you think it would be?*
If you don't think s/he'd change anything about you, then what would s/he change about her/his lifestyle?
If you had to make up a creative name for your dog's personality type, what would it be & why?*
If you had to make up a creative name for YOUR personality type, what would it be & why?*
Yes, we know this is a bit silly. Humor us?
What issues, behaviors, &/or training would you like help with?*

AggressionAnxietyAttentionBasic Skills (e.g., Sit, Lie Down, Come, Walk on Leash, etc.)Biting / Nipping / MouthingDrop it / GiveEnrichmentFearHousetrainingIntroductionsLeave ItLoose Leash WalkingLungingPTSD/TraumaReactivityRecallAll Behavior Modification FoundationsAll Positive Reinforcement FoundationsOther
Please give details on your selections above.*
What type of learner are you? Please choose the main one.*

Visual (images, photos, graphs help more than words)Auditory (Discussions, lectures, conversations help most)Kinesthetic (Physical practice/experiences)Reading/Writing (Writng notes, reading written words)Other
Which of these traits best describes you:*

Laid-backResoluteRestlessSkepticalForgetful
What do you feel is the FIRST/MOST IMPORTANT thing that you and your dog need help with?*
What really matters to you about the dog training or behavior consulting process?*
Why is it important to you to achieve the result you hope for?*
Investment constraints: About what do you envision spending in time and money to achieve your goal?*

As much time as it takes, flexible budgetAs much time as it takes, between $300 and $500 totalLess than $3000 total over no more than six monthsI only have a couple of weeks to reach my goal but I have no budget limitI want to resolve the issue/reach my goal in no more than three sessions.My budget is somewhere between $500 and $2000.I would like to spend no more than a few months on this.I do not envision practicing maintenance training once sessions are complete.I envision practicing maintenance training once sessions are complete.Once my current goal is reached, I'd like to work on another.Other
What kind of work do you do or, if retired, did you do before? (occupation)*
Where did you hear about Expert Canine?*
Sorry to ask, but as someone with an autoimmune disorder, I must: Is everyone in your household willing to wear a well-fitted N95 mask if I need to visit in person? (Generally services are provided via Zoom.)*
Yes or No
Your Full Legal Name:*
Date Signed:*
Your Signature (full legal name)*

Clear
Sign with your fingertip or your mouse.
Should be Empty: