Canine Coach - Intake Form
Are you a...?
*
New client
Previous client
Name
*
First Name
Last Name
How did you hear about us?
*
Friend/Family
Web Search
Veterinarian
Other
Family Members and ages (if applicable)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Phone
*
Please enter a valid phone number.
Email
*
example@example.com
Preferred method of communication (Choose one)
*
Phone
Email
Text
When are you available for lessons? (Choose all that apply)
*
Weekday
Evening
Weekends
Veterinarian
*
Veterinarian Phone #
*
Please enter a valid phone number.
DOG
Name
*
Breed
*
Date of Birth
*
Sex
*
Male
Female
Is your dog neutered or spayed?
*
Neutered
Spayed
Intact
What previous training has your dog had?
*
What can we help you with? (check all that apply)
Manner's Training
Polite Leash Manners:
In your neighborhood
On trails
In crowds (events, festivals, etc)
Other
Coming when called:
In your home
In your fenced yard
In your unfenced yard
In parks
In dog park
Trails
Other
Jumping Up:
On family members
On strangers during walks
On visitors to your home
On counters
Other
Boundary training in home:
Off limit areas
In unfenced yard
Other
Other:
Leave it
Drop it
Stay
Waiting at door
Behavior Modification
Aggression towards people:
Family members
Visitors
On leash
Barking
Lunging
Growling
Snapping
Biting
Other
Aggression towards dogs:
On leash
In the home
Fence fighting with neighbor dog(s)
Barking
Lunging
Growling
Snapping
Biting
Other
Does your dog have Separation Anxiety?
Yes
No
DOG #2
Dog #2 Name
Dog #2 Breed
Dog #2 Date of Birth
Dog #2 Sex
Male
Female
Dog #2 Is your dog neutered or spayed?
Neutered
Spayed
Intact
Dog #2 What previous training has your dog had?
What can we help you with (Dog #2)? (check all that apply)
Manner's Training
Polite Leash Manners:
In your neighborhood
On trails
In crowds (events, festivals, etc)
Other
Coming when called:
In your home
In your fenced yard
In your unfenced yard
In parks
In dog park
Trails
Other
Jumping Up:
On family members
On strangers during walks
On visitors to your home
On counters
Other
Boundary training in home:
Off limit areas
In unfenced yard
Other
Other:
Leave it
Drop it
Stay
Waiting at door
Behavior Modification
Aggression towards people:
Family members
Visitors
On leash
Barking
Lunging
Growling
Snapping
Biting
Other
Aggression towards dogs:
On leash
In the home
Fence fighting with neighbor dog(s)
Barking
Lunging
Growling
Snapping
Biting
Other
Does your dog have Separation Anxiety?
Yes
No
DOG #3
Dog #3 Name
Dog #3 Breed
Dog #3 Date of Birth
Dog #3 Sex
Male
Female
Dog #3 Is your dog neutered or spayed?
Neutered
Spayed
Intact
Dog #3 What previous training has your dog had?
What can we help you with (Dog #3)? (check all that apply)
Manner's Training
Polite Leash Manners:
In your neighborhood
On trails
In crowds (events, festivals, etc)
Other
Coming when called:
In your home
In your fenced yard
In your unfenced yard
In parks
In dog park
Trails
Other
Jumping Up:
On family members
On strangers during walks
On visitors to your home
On counters
Other
Boundary training in home:
Off limit areas
In unfenced yard
Other
Other:
Leave it
Drop it
Stay
Waiting at door
Behavior Modification
Aggression towards people:
Family members
Visitors
On leash
Barking
Lunging
Growling
Snapping
Biting
Other
Aggression towards dogs:
On leash
In the home
Fence fighting with neighbor dog(s)
Barking
Lunging
Growling
Snapping
Biting
Other
Does your dog have Separation Anxiety?
Yes
No
Please review our Policies and Procedures:
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