Zippity Do Dog Behavioral Intake Form

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You are about to complete an detailed intake form, before you begin please confirm that you are in my service area:

Attleboro, Attleboro Falls, Berkley, Dighton, Easton, Foxboro, Mansfield, North Attleboro, North Dighton, North Easton, Norton, South Easton, North Attleboro, Plainville, Raynham, Rehoboth, Sharon, Taunton.

If you do not see your community listed here, please reach out to me before completing this form, I am often able to make accomodations.

Details

Please understand that consultations are a limited opportunity. By chosing a date to meet and submitting payment, you are taking away and opportunity from someone else who may be in a desperate situation, therefore the consultation fee of $195.00 is non-refundable. No exceptions. If you need to reschedule, no problem. You will have 90 days from the date of this form submission to use your credit.
This form is for one dog (exception is fighting between two dogs within the same household)
This consultation will take place in your home.
In most cases I do not need to see the behavior that your dog is struggling with, chances are I have seen it many times before with other dogs. I prefer to not upset your dog by putting them in a situation that is going to cause them stress and anxiety. The purpose of this intake form is to gather details and then during our meeting I will gather additional information.
Do not skip questions. Answer with an NA if it doesn't apply to you.
Be thoroughly honest in your answers. This is a judgement free zone.
You will receive a comprehensive follow-up report that outlines the why of your dog's behavior, that includes my recommendations and a training plan.
A consultation is not a remedy or replacement for behavioral training.

I look forward to meeting with you and your dog.

Phone Number

Please enter a valid phone number.

Name

First NameLast Name

Address

Street Address

Building number Apt number

CityState / Province

Postal / Zip Code

Email

example@example.com

What is the best way to reach you quickly?

Phone callEmailText

Who else lives in the home? (include college students who live at home part time, etc.)

If your live with other people, who will be participating in training?

How did you hear about me?

What is your dog's name?

What breed or combinations of breeds is your dog?

Have you DNA tested your dog?

Dog's age?

Dog's sex?

Are there any other pets in the home? Please list.

Is your dog spayed or neutered?

At what age were they spayed or neutered?

What is your dog's current weight?

Coat type and color.

Where did you get your dog? (Include name or shelter/rescue/breeder).

Why did you get your dog? (Companionship, watchdog, sport competition, playmate for current dog, etc.)

What made you choose your breed if you got yourbreed from a breeder? What made you adopt your dog if you adopted your dog froma rescue or shelter?

What do you know about your dogs breed(s)?

If you got your dog as a puppy, how old was s/he when you brought him/her home?

Early history if known (birth conditions, litter size, temperment of parents, amount of human and animal contact, early rearing experiences, traumatic events health and emotional state when brought into your home, etc.)

How would you describe your dog's personality? Here are some examples of what people often say: "Party Animal", "Kamikaze", "Afraid of Life", "Loner", "Aloof", "DIsconnected", "Stubborn", "Social Butterfly", "Ready for Action", "ADHD", "Hair Trigger", "Couch Potato", "Pushy", "Depressed", "Lap Dog", etc.)

Have there been any significant changes recently in your dogs life? (a move, pet or person passed away or moved out, diet changes, illness, construction, etc.)

Do you use a crate for this dog?

How much time does your dog spend alone:

Where des your dog stay when home alone?

Where does your dog sleep at night?

Is your dog allowed on furniture?

Is your dog social with unfamiliar people?

Seems to love just about everyoneGood with unfamiliar womenGood with unfamiliar menGood with unfamiliar childrenTolerant (okay in their presence but doesn't like to be touched by strangers)Scared, avoids strangersAggressive, barks, gowls and lungesSelective

If you chose selective above, please explain.

Has your dog ever bitten anyone? Please be honest. If your dog has bitten that doesn't mean I won't work with them.

No, not to my knowledgeI'm not sure if it was play or aggressiveMy dog has growled but never bittenYes, but it left no markYes, the bite left a shallow punctureYes, the bite left multiple puncturesYes, my dog has bitten multiple times

Please explain the circumstances that occured just before and around the time of the bite:

Please describe the severity of the injuries inflicted:

Has your dog injured or killed another animal?

Does your dog appear sensitive to sounds in the environment, causing behavioral responses (running to hide, shaking, howling, etc.)

High Level (car alarm, lawn mower)Low Level (power tools being used at the neighbors)Squeaks (from children or toys)Buzzers (dryer, dishwasher, microwave)Thunder and Lightening StormsFireworks or big bangs like itCars, trucks, motorcycles, driving by or backfiring, horns)

If your dog is sound sensitive, how do they respond? (panic, look for a place to hide or try to run away?)

What have you tried, to sooth your dog during these times?

Is your dog motion sensitive? How does your dog react toward objects or small animals that move quickly (birds, chipmunks, squirrels, bunnies, roomba, reaching past them)

Is your dog touch sensitive? How does your dog respond to nail trims, ear cleaning and teeth being brushed?

Does your dog travel well? How do they travel (crate, backseat, car restraint)? Does your dog pant, drool, pace, whine, freeze, or become ill in the car or when confined?

Is your dog motivated by food/treats?

YesNo

If you don't believe that your dog is motivated by treats, please indicate the reasons why. What you have tried using, and where were you (setting), and what were the distractions?

Is your dog motivated by toys?

YesNo

If the answer is Yes what are some favorites?

Current level of activity: what the ways your exercise your dog?

How is your dog fed?

Breakfast and DinnerJust BreakfastJust DinnerI leave it down and they eat when they eat

Do you currently have any of the following for your dog? (check all that apply)

Would you be interested in an enrichment plan for your dog?

YesNo

What is your dog's "happy place"? When are they the most content (excluding sleeping)? What are their favorite activities?

What makes your dog most anxious?

What are your dog's least favorite activities (this can be anything)?

What equipment do your use to walk your dog?

Do you (or a dog walker) walk your dog using a Flexi-Leash or other Retractable Leash?

Has your dog ever worn an Electronic Collar?

How do you reinforce desirable behaviors?

PraiseFood rewardsToy rewardsLife rewards (walks, sniffing, playtime)

How do you address undersireable behaviors? (jumping, barking, etc.)

List any medications (including preventatives and herbal remedies) your dog is currently on:

Does your dog have allergies?

Veterinarian's Name & Clinic/Hospital

May I contact your veterinarian or previous trainer for their persectives on and experiences with your dog as it relates to your dog's issues? If so please provide their contact information.

Date of last visit (approximate is okay)

How does your dog handle going to the vet?

Have you noticed any of the below? Check all that apply (look over your dog now)

Please list any injuries (not related to today's issues)

Please describe any surgeries

Chronic Health Issues

How long have you been dealing with the issues that have brought you here today?

Has your dog had previous training?

Who is the trainer you previously or are currently using?

Please select any skills that your dog currently has that are 90% reliable across all settings in the presence of distractions. (Example: Stay in a sit, down or leave-it position while you leave the room and disapear from sight, or remain sitting outside while children run around them)

Thinking about the issues that have brought you here today, what was the previous treatment sought for the these issues?

Name of trainer (and training facility if applicable) that you used for the problem that brought you here today.

If you didn't use a trainer for these issues, how have you tried to fix these issues (please give a detailed example)?

Please select any methodology used to address any behavioral issues that your dog has experienced.

What resources have your turned to for self education on dog training? (Videos, TV shows,YouTube, Books, FB Pages, IG)

Thinking about any other areas of concern that you would like to discuss with the trainer:

List the top three behaviors that you would like to change.

Is there anything else, not covered in this intake form that you would like me to know?

When I look at a dog and see their limitations, I remind myself that they can be given the opportunity to shine in whatever ways they have the potential for shining. It might not look like another dog's glow, but that does not matter. Keep an eye out for the sparkle. It's there."-Debbie Jacobs

Tell me the things that you love about your dog.

Date*

Date

Hour Minutes

Consultation Payment *

USDNon-Refundable Payment for Behavioral Consultation

Signature*