Pupcakes Rescue and Rehab

Pupcakes Rescue and Rehab

Enquiry for rehabilitation and assessment placement
To enquire about available spaces for behaviour and assessment placements, please complete the following form.
Information about the Charity/Organisation
Name of Charity/Organisation *
Primary Address of Charity/Organisation*

Street Address

Street Address Line 2

CityCounty

Post code
Contact name*

First NameLast Name
Position held within Charity/Organisation
Primary contact number*

Area CodePhone Number
Alternative contact / mobile number*
Please enter a valid mobile number.
Email*
Example- dogrescue@gmail.com
Please select ways we can contact you:*

LandlineText messaging (sms)WhatsAppMobile callLetterEmailFacebook messenger
About the Dog.

For us to be able to assess your request, please fill in as much information as possible
Dog’s name:*
Breed:*
Sex:*

FemaleMale
Age:*
Neutered*

YesNo
Vaccinated*

YesNo
Date of last vaccination

DayMonthYear
Behaviour assessment

To help us determine the best training/support approach necessary to helping the dog, please fill in as much information as possible.
What support are you requesting from “Pupcakes Rescue and Rehab”?*

RehabilitationTrainingBehaviour and management assessment
Please feel free to explain further how you would like “Pupcakes Rescue and Rehab” to assist in your request for a behaviour/assessment placement.
Rehabilitation or training you would like us to undertake or evaluations you would like for us to put together for your organisation
Does the dog have a bite history?*

YesNo
Bite level-
Please select all known options relevant to the dog- if exact triggers are unknown please select "undefined" in the relevant catagory
Resource guarding:

Possessive aggression- spacePossessive aggression- personal anatomyPossessive aggression- toys/other dogs/lead/objects/furniturePossessive aggression- foodPossessive aggression- person/peopleUndefined possessive aggression
Reactivity:

Human reactiveDog reactiveNoise reactiveEnvironmental reactiveLeads to redirected aggressionUndefined reactivity
Anxiety:

Separation anxietyFamilial aggressionIllness induced anxietyTrauma anxietyNoise sensitivityStranger-phobicDestructiveUndefined anxiety
Please explain the circumstance(s) of the behaviour and/or bite(s), if known:
Has the dog seen a Veterinary professional to rule out pain/health causes for the behaviour, if so please explain?*
Please attach a clear photo of the dog: *

Cancelof
I consent to “Pupcakes Rescue and Rehab” storing my personal details on their database should I need to be contacted*

I agree
I confirm that I have the authority of the Rescue/Organisation to consent for their data and information to be processed for the following purposes:*

To assess eligibility of the dog for a rehabilitation and/or assessment placement under “Pupcakes Rescue and RehabTo share data and information with “Pupcakes Rescue and Rehab” colleagues, behaviourists and Veterinary Professionals for evaluation of the dog and it’s behaviours before/if a placement is offered.For “Pupcakes Rescue and Rehab” to store the information and data of the Rescue/Organisation on their database to allow them to contact them if required, and to keep a record of the dog I am requesting placement for.I am aware that consent for my personal data and that of the Rescue/Organisation can be withdrawn at any time by contacting “Pupcakes Rescue and Rehab”
Should be Empty:

Pupcakes Rescue and Rehab

Information about the Charity/Organisation

About the Dog.

Behaviour assessment