2023 EHS Dog Surrender Form

EHS Dog Surrender Form
We understand that surrendering a pet can be a difficult and emotional decision to make, and appreciate that you are doing what is best for your pet and your family. Before bringing in your pet, we ask you to please complete the following questions so we can determine how we can best help.

The following questionnaire will take you approximately 25 to 45 minutes to complete, and you may save your spot in the questionnaire at any time and return to it later. While the questionnaire may seem long, completing this information as thoroughly as possible is important to ensure we can meet your dog's needs.

Please complete one form per dog. If you are looking to surrender a litter of puppies, please email us instead.

A copy of your form will be emailed to you for your own records after you complete it.

All animal surrenders at the Edmonton Humane Society are done by appointment only, based on the resources and space we have available to care for your dog at this time, so we can provide the best possible care once they arrive. Wait times may vary (from weeks to months) depending on your dog's needs.

Please note that at the surrender appointment we will require proof of ownership, or proof that you have the authority to surrender the dog on behalf of the owner.

If we are unable to admit your animal, we will do our best to provide alternative options or may put you on our waiting list.

After completing the following questions, our team will review the form and will be in contact with you within 10 business days to let you know when we may be able to admit your dog and go through the next steps. We may also contact you with additional questions.

PLEASE NOTE: We currently have a waitlist and cannot guarantee a timeline in which we could accept your animal into our care. We recommend also pursuing other options like rehoming.
(Last Update - March 2023)

If you have any further questions about this process, you can contact our Admitting Team at 780-491-3522 or admissions@edmontonhumanesociety.com.

Owner Details

Please tell us about yourself
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal Code
Primary Phone Number *

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email*
example@example.com
Have you ever owned a dog before (prior to your current one)?*

YesNo
Have you ever owned this breed of dog before (prior to your current one)?*

YesNo
Have you owned any other type of pets previously?*

YesNo
How many people (including yourself) currently live in the household? *
Please list the ages of all members currently living in the household (including kids):*
Ex. 2, 8, 16, 38, 42

Behaviour Support Options
You mentioned on the previous page that your primary reason for surrendering your dog was due to a behaviour issue.

The Edmonton Humane Society has trainers who do private behaviour consulations and training classes that could help you explore potential solutions to the issue(s) you are experiencing, before you proceed with surrendering.
Would you be interested in meeting with one of our trainers for a private consultation to explore possible solutions before you proceed with surrendering your dog? The cost of a 90 minute session with a trainer is $150+GST, and if you still chose to proceed with surrendering after the consultation we would waive the surrender fee.*

YesNoI'd like to speak with someone about a consultation before I decide
Would you be interested in taking a group class with your dog if there was one that fit the behaviour issues you are experiencing? A six week class is $190+GST, and if you still choose to proceed with surrendering after taking the class we would waive the surrender fee.*

YesNoI'd like to speak with someone about the training classes before I decide
If you answered yes to any of the above questions or indicated you'd like to speak with someone, a member of our training team will be in contact with you. Please proceed with completing the form, as this information will help our trainers determine how they can help.

Behaviour & Medical Cases
You have indicated that the primary reason you are requesting to surrender your dog is for a medical or behaviour reason.

As animals with these needs often require a longer stay in shelter and increased support for their recovery/rehabilitation, we may not be able to admit them as quickly depending on the space, resources and other animals currently in our care. It may take weeks to months for a space to become available.

In the meantime, we encourage you to check out the local resources for behaviour and medical issues on our website here. Our team will also try to provide alternative suggestions when we contact you.

If you would still like to proceed with your surrender request, please check the box below and complete the form to tell us more about your pet. This will help us to better assess what kind of care they will need and determine when we can take them in.
*

I understand that it may take longer for a surrender appointment to become available for my pet, based on their behaviour/medical needs. I would like to be placed on the wait list in the meantime.

Other Pets

Please provide details of your other household pets to help us determine what kind of animals your dog may or may not get along with.

Other Household Pets

	Animal Type	Breed	Age	Spayed/Neutered?	Relationship with Dog (ex. avoids, plays, fights)
Pet #1
Pet #2
Pet #3
Pet #4

Dog Details - Home Life
What areas of your home does the dog have access to? *
Where does your dog sleep at night?*
What does your dog do when people are eating meals?*
Have there been any recent changes to your household routine? Please select ALL that apply.*

New work hoursNew babyMoving/movedNew roommate or visitorsBoardingDiet changesOther
Please provide details of the above mentioned change(s):

Dog Details - Training & Obedience
Has your dog ever attended training classes?*

YesNo
What kind of training class(es) did the dog attend?
What type of training techniques and methods were used in class?
Ex. clicker and treats, reward-based, dominance/alpha training, punishment
How did your dog do in the class? If asked to leave class, please explain why.
What kind of training methods have you used at home? *

Dog Details - Personality
How would you describe your dog's personality? *
What are your dog's best qualities?*
What would you like us to know about your dog when caring for them? *

Dog Details - Behaviour Problems: Other

You mentioned that you've been experiencing behaviour issues with your dog that are not house soiling, destruction or aggression. Please answer the following to provide some more details on the problem(s).
Please describe the behaviour problem(s) you are currently experiencing:*
When did these problem(s) begin? *
How old was the dog when these problem(s) began? *
Where does the problem(s) occur?*
Ex. home, veterinarian, dog park, on walks
With who does the problem(s) occur with?*
Ex. kids, family, strangers, other dogs, other pets
How often does the problem(s) occur?*
Ex. daily, every few days, only in certain situations (please specify)
How do you respond when the problem(s) occurs? *
What have you done to try correcting the problem(s)? *
How has the problem(s) progressed?*

Getting betterGetting worseNo change
What do you think may be the cause of the problem(s)?*

Dog Details - Last Question
Is there any other information we haven't asked about your dog that you feel is important for us to know?
Thank you for taking the time to fill in these questions as completely as possible. This information is important for us to be able to help your dog as best as we can.

A copy of your form will be emailed to you for your own records once you hit 'Submit'. A team member will then review your form and contact you within 3 business days to let you know when we may be able to admit your dog or if more information is required.

Please Note: We are working to resolve some technical issues with our forms. After submitting - if you do not receive a response from our admitting team within 10 business days - please email: admissions@edmontonhumanesociety.com
Please verify that you are human*
Should be Empty:

	Name of Medication	Dose	Frequency
1.
2.
3.
4.
5.
6.
7.
8.

	1 - No	2 - Sometimes	3 - Often
Does your dog get lost when outdoors?
Does your dog get ‘stuck’ in corners or under furniture?
Does your dog stare off into space or at walls?
Does your dog wander aimlessly around the home?
Does your dog whine or bark for no apparent reason?
Does your dog stare at his reflection in windows or mirrors?
Does your dog bump into objects at home?

	1 - No	2 - Sometimes	3 - Often
Does your dog greet you differently from how he used to?
Does your dog interact with visitors differently than he used to?
Does your dog want less interaction /affection than he used to?
Is your dog more withdrawn than he used to be?
Is your dog more irritable than he used to be?
Does your dog startle more than he used to?
Is your dog more aggressive than he used to be?

	1 - No	2 - Sometimes	3 - Often
Does your dog wake you up at night?
Does your dog sleep more in the daytime than he used to?
Is your dog difficult to rouse from sleep?
Does your dog have difficulty settling down to rest?
Is your dog more active during his sleep than he used to be (i.e. he appears to be twitching or moving while dreaming)?

	1 - No	2 - Sometimes	3 - Often
Has your dog stopped eliminating in the proper location?
Does your dog urinate indoors?
Does your dog defecate indoors?

EHS Dog Surrender Form

Owner Details

Dog Details

Behaviour Support Options

Behaviour & Medical Cases

Other Pets

Dog Details - History

Dog Details - Medical

Dog Details - Cognitive Assessment

Dog Details - Diet & Feeding

Dog Details - Exercise

Dog Details - Home Life

Dog Details - Training & Obedience

Dog Details - Personality

Dog Details - Behaviour

Dog Details - Behaviour Problems: House Soiling

Dog Details - Behaviour Problems: Destruction

Dog Details - Behaviour Problems: Aggression/Bite History

Dog Details - Behaviour Problems: Other

Canine Behavioural Assessment & Research Questionnaire (C-BARQ)

Part 1: Excitability

Part 2: Aggression

Part 3: Fear and Anxiety

Part 4: Separation-related Behavior

Part 5: Attachment and Attention-seeking

Part 6: Training Difficulty

Part 7: Miscellaneous Problems

Dog Details - Last Question

	1 - No	2 - Sometimes	3 - Often
Is your dog less physically active that he used to be?
Does your dog lick or chew himself more than he used to?
Is your dog more restless than he used to be?
Does your dog pace in a fixed pattern repeatedly for no apparent reason?
Does your dog play less than he used to?
Does your dog seem more vigilant than he used to be?
Is your dog less interested in eating than he used to be?
Is your dog less responsive to you than he used to be?
Is your dog more anxious than he used to be?
Is your dog more anxious when left alone than he used to be?
Is your dog more sensitive to noise than he used to be?
Does your dog press his head against anything?
Does your dog tilt his head for no apparent reason?

	Never	Seldom	Sometimes	Usually	Always	Not Applicable
22. Restlessness/ agitation/ pacing
23. Barking or whining
24. Chewing/ scratching at doors, floors, windows, curtains, etc.

	Never	Seldom	Sometimes	Usually	Always	Not Applicable
25. Tends to follow you (or other members of the household) about the house, from room to room.
26. Tends to sit close to, or in contact with you (or others) when you are sitting down.

	Never	Seldom	Sometimes	Usually	Always	Not Applicable
27. Obeys a "sit" command immediately.
28. Obeys a "stay" command immediately.
29. Easily distracted by interesting sights, sounds or smells.

	Never	Seldom	Sometimes	Usually	Always	Not Applicable
30. Chases or would chase birds, given the chance.
31. Chases or would chase squirrels, rabbits, etc., given the chance
32. Escapes or would escape from home or yard, given the chance.
33. Chews inappropriate objects.
34. Pulls excessively hard when on the leash.
35. Urinates against objects/ furnishings in your home.
36. Urinates when left alone at night, or during the daytime.
37. Defecates when left alone at night, or during the daytime.
38. Hyperactive, restless, has trouble settling down.
39. Playful, puppyish, boisterous.
40. Active, energetic, always on the go.
41. Chases own tail/hind end.
42. Barks persistently when alarmed or excited.