Monthly survey
Name
*
First Name
Last Name
Dog name
*
Today's Date
-
Month
-
Day
Year
Date
Client Services Coordinator
*
Please Select
Elizabeth Reberk
Denise Yokom
Jen Gravrok
Jenny Brisson
Alaina Albert
Elizabeth Reberk
example@example.com
Denise Yokom
example@example.com
Jen Gravrok
example@example.com
Jenny Brisson
example@example.com
Dog's weight
*
Date weighed
*
Location weighed
Type of dog
*
Mobility Assistance Dog
Seizure Response Dog
Diabetes Assist Dog
Hearing Assist Dog
Autism Assist Dog
Since certification, has your dog been taken to a veterinarian for any reason?
*
If yes, please explain
Since your certification, have you experienced any problems with access to public places or with your dog while in public?
*
If yes, please explain
How satisfied are you with your dogs...
*
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
Basic Skills (sit, down, etc.)
Tasks (retrieving, alerting, etc.)
Ability to be groomed
Behavior in public
House manners
If you selected not satisfied or somewhat satisfied, please explain
How reliably is your dog performing...
Not reliably
Somewhat reliably
Reliable
Very Reliable
skills (sit, down, etc.) when asked
tasks (retrieves, alerts, etc.) when asked
cooperative grooming
If you selected not reliably or somewhat reliably, please explain
How often is your dog helping you?
What skills does your dog do naturally?
Which skills do you need to train?
Have you needed further assistance from your Client Services Coordinator since your team certification?
*
Did your Client Services Coordinator provide you with the assistance you needed?
*
If yes, please tell us how they helped you solve the problem.
If no, would you like assistance with the problem now? Please describe the problem
How many times per week do you practice the skills you would like your dog to perform for you during or after a seizure?
*
Have you seen any indication that your dog knows a seizure is about to occur?
*
If yes, please explain
How many times per week do you practice the tasks that your dog has been trained to do for you?
*
Have you experienced any problems with your dog performing the tasks that he/she was trained for?
*
If yes, please explain
When your dog responds to a sound how does he/she alert you? (Barks, jumps on you, nudges you, uses paw touch, etc.)
*
Is the alert that the dog uses consistent?
*
If no, please explain
Is your dog consistently alerting you to the sounds that he/she was trained for?
*
If no, please explain
Is your dog consistently alerting you to the sounds that he/she was NOT trained for?
*
If yes, please describe
What percentage of your low blood sugars is your dog alerting you to at this time?
*
How many times per week are you practicing the scent game with your dog?
*
When your dog signals a hypoglycemic episode how does he/she alert you?
*
Is the signal the dog gives consistent whether you are at home or in public?
*
If no, please explain
Have you noticed a lessening of anxiety or a change in your child's behavior while in public with the assistance dog?
*
If yes, please explain
Have you noticed a change in your child's sleep patterns since the arrival of his/her assistance dog?
*
If yes, please explain
Please describe any changes you have noticed in your child, both at home and in public that you attribute to the presence of their assistance dog
*
Have you taught your dog any new skills or tricks that you are finding helpful or fun?
*
If yes, please explain what they are
Please share with us any cute, funny or profound stories about your new canine partner.
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