Separation Anxiety Client Intake Form
Name
*
Email Address
*
Phone Number
Please enter a valid phone number.
Your Dog's Name
*
What’s your dog’s date of birth? (put approximate if adopted)
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Month
-
Day
Year
Date
What date did you get your dog?
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Month
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Day
Year
Date
Where did you get your dog from?
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How long has your dog had separation anxiety? (months, years etc)
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What breed or mix is your dog?
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Is your dog spayed/neutered?
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Yes
No
Is your dog female or male?
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Male
Female
Please list other members of the household. If there are children in the home please indicate their ages.
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Do other pets live in the home? If so please list how many and what type of pet.
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Please list out the daily exercise and enrichment your dog gets.
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How long is your dog being left alone at the moment?
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Have you spoken to your vet about your dog’s separation anxiety?
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Yes
No
If yes, what was the outcome of your conversation with your vet?
For separation anxiety training to work, it would be better to find a way to stop leaving your dog. How do you feel about that?
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That’s unrealistic
Might be doable
I’m already doing that. My dog is never left alone.
Other
What other training have you done to address your dog’s separation anxiety? Please outline below.
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Please give me any more background about your dog that you think might be helpful.
*
How did you hear about us?
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Friend/Colleague/Relative
Online search
Facebook
Dog trainer
Vet
Other
Please provide the name of the business or person who referred you.
I would love to have a photo of your dog!
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I agree to allow the photo submitted to be used on the business social media pages of Khris Erickson, LLC. The purpose of these postings would be to highlight the success of the training. No identifying client information other than the name of the dog would be posted.
Yes
No
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