Dog Adoption Questionnaire

Hearts Healing Hearts

Potential Dog Adopter Survey
This questionnaire is to help us help you find your ideal dog.

Please allow approx. 15 minutes to fill in this form.

It is very detailed to give us the most information possible so we can work with our rescue partners in finding your new family member.
Adopter's Information:
Your Name (First & Last): *
Street Address: *
City, State, Zip *
Phone Number: *

Area Code Phone Number
Alternate Phone:

Area Code Phone Number
E-mail: *
How do you prefer to be contacted? *

Email Text Phone
About Adopter:

There are no wrong answers. We want to get a feel for what you're looking for and how much experience you have so we can help you find the RIGHT dog for your family.
Choose which best describes your level of dog owning experience: *

Advanced (Dog behavior & training background) Intermediate (Always owned dogs) Novice (been around dogs but never had the responsibility of one) Beginner (Never had a dog)
What qualities are you looking for in a companion?
Are you concerned with any of the following behaviors? *

Jumping Barking Pulling on leash Refusal to be handled Mouthing Fear/Anxiety
Which of the above listed behaviors are you willing to work through, with training & support? *
What activities would you like to do with your new pet?
Would you consider adopting a pet with existing medical needs? *

Yes No Maybe
Do you prefer a dog with long, wire or short hair? *

Long hair/fluffy Wire hair Short hair no preference
Many dogs require regular grooming. Are you prepared for the costs of grooming, especially long haired or fluffy dogs? *

Yes No Need more info
What do you plan to do with the dog if you move? What if there are restrictions pertaining to your pet? *
Who will care for the dog during times you are away (vacations, business trips, etc.)?
Who will inherit the animal in the event of a death?
Household Information:

We work with a lot of different rescue groups to find great homes for the many homeless dogs in the area. These questions will help different rescue groups who require different criteria but will not necessarily disqualify you from getting a dog.
Do you consent to a brief home visit, prior to finalizing the adoption of your new dog? *

Yes No
Are all members of your household in agreement with this adoption? *

Yes No I Don't Know
Who will be the dog's primary caregiver? *
Do you own or rent? *

Own Rent
If renting, please provide name and contact number for landlord/property management: *
Does your landlord/property management/HOA allow dogs at your residence? *

Yes No
Are there any restrictions from your landlord/property management/HOA? *

Number of pets Size or weight restrictions Breed restrictions None
If restrictions: what sizes/breeds/etc.
Size of your backyard: *

Small Average Large Extra Large (Corner lot) Patio (No Yard)
Do you have a fully fenced yard? *

Yes No
Height & type of fence: (N/A if not applicable or no fence) *
Where will the dog be kept when you are not home? *
Does your yard include a pool? *

Yes No
If yes, are there safety precautions to keep the dog from unauthorized access?
How many adults are in your household? *
How many children under the age of 18 are in your household? *
Please list children's ages:(N/A if no children) *
Have children in the home been around dogs, before? *

Yes No
Does anyone in your home have asthma or pet related allergies? *

Yes No
Household Activity Level:

Quiet Active Very Active Just Me
Please list 2 personal references with phone numbers: *
Current Pet Information:
How many animals currently live in your home? *
Please list all current pets in the household: (Name, age, breed, type) *
Are your current pets spayed/neutered? If not, please explain why. *
Are your current dogs/cats up to date on their rabies vaccination?
Have you ever adopted from a rescue group or shelter? *

Yes No
If yes, which rescue/shelter? *
Have you ever had to surrender an animal? *

Yes No
If yes, please briefly explain the circumstances?
Do you have a vet you use, currently? *

Yes No I would like help finding one
If so, please provide the name, address, & phone number of your vet:
Adoption Information:

Please tell us a bit about what you have in mind. Have you thought about grooming requirements? What about drool levels, potty training, obedience, etc.?
How long have you thought about getting a dog?
Briefly explain why you are interested in adopting? *
What are you hoping a dog will bring to your life? *
What is your ideal breed or breed mix? *
Do you want your dog to be: *

Male Female Either
What age dog do you prefer? *
What size dog do you prefer? *

Giant (over 80 pounds) Large (55 to 80 pounds) Medium (30 to 54 pounds) Small (5 to 29 pounds) Tiny (under 15 pounds)
What, if any, breeds are you NOT interested in? *
What is your preferred activity level for the dog? *

High Energy/Jogging buddy Moderate Activity Low Activity Couch Potato
We highly recommend crate training: would you like more information on the benefits of crate training or how to crate train? *

Yes No Maybe
Will your new dog be allowed on the furniture? *

Yes No Some pieces
How many hours each day will your new dog be home alone? *
How do you plan on helping your new dog best adjust to their new home? *
What will you do if bad habits form? *
Are you willing to utilize support & training tools, if any behaviors or concerns arise? *

Yes No
Under what circumstances would you have to give up your dog? *
Have you ever potty-trained a dog before? *

Yes No Could use help with this
Even dogs who are house trained will have to learn how to tell you when they need to go out and they will need to learn where to go.

It can take days or weeks for a new dog to learn where and when to go potty. Be patient, it's a learning process.
Is there any information we haven't covered that you would like to share in helping find your perfect dog?
How hear about Hearts Healing Hearts? *

Google Facebook Instagram Friend/Family
By submitting this form I agree that the information I have provided is true.

I understand that filling out this survey does not guarantee adoption. I understand that a meet & greet with a dog does not guaruntee adoption.

I understand that Hearts Healing Hearts works on donations. Those donations help us help dogs and are grately appreciated.

I understand that rescue partners do charge adoption fees that go towards the care & medical needs of the dogs they help.
Please allow The Hearts Healing Hearts volunteer team 2-3 business days to process your application.

We will reach out to our rescue partners to try to find the dog that meets the majority of your requests.

You will be contacted by email, phone or text as provided, by Hearts Healing Hearts or the rescue partners who may have a dog they believe meet your criteria. [Your information will only be shared with the rescue groups who have partnered with us and have agreed to high privacy standards.]

Thank You for allowing us to be part of your rescue adoption process.
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Adopter's Information:

About Adopter:

Household Information:

Current Pet Information:

Adoption Information: