Behaviour Assessment Questionnaire

Behaviour Assessment Consultation Form
Thank you for your interest in learning more about your dog and their behaviour. Understanding our dogs is the foundation of our communication. Our vehaviour consults are very different from most canine behavioural assessments. ALL aspects of both you and your dogs day to day life are taken into consideration from their behaviour, to what they eat, to the way they move, sleep, play and routine. Working with a sound knowledge of the inner structures and systems of the dog, we understand the impact that emotional and physical health may have on a dogs behaviour. Everything is connected, and that is why we insist on a FULL and DETAILED assessment when working with you & your dog.What to expect on top of the standard behaviour assessment? All About your Dog - Deep Dive This iscarried out on Zoom depending on your location. Lasting approximately 60-90 mins we take a look at what life is like for you and your dog. Be warned we want to know EVERYTHING which often leads us down previously unexplored territory. Data Gathering - Additional information in visual form - photo's and video's of your dog doing various activities of daily life so we can assess any physical issues. Evidence Analysis. We then spend 48hrs going over all the data & information given to us in the consult so we can build the full picture of what is going on for your dog. If a Veterinary Report & Liaison is needed. We then construct a comprehensive veterinary report with corresponding evidence with our findings to ensure that any underlying health issues are diagnosed and supported so that they lesson the impact on your dogs behaviour. Behaviour Management Plan - This may be a short term to help you micro manage behaviour while additional Veterinary support is given or longer term help can be discussed depending on assessment outcomes.
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Who should I thank for referring you to my services?*
Dog's Name*
What Breed is your dog.*
Dog's Birthdate*
Is your dog?*

MaleFemaleNeutered/Spayed
How long have you have your dog?*
How old was your dog when you got him /her?*
Veterinarian Contact Info?*
Why did you get your dog?*
List any other pets in the home. Name , age, type, breed.*
Have you done any training with your other dogs?*

YesNo
List other people in the home, name, relation age.*
Where does your dog stay while you are Home with them?*

inside, with supervisioninside, free reininside, crateinside, contained to a roomoutside, fenced in yardoutside, on a cable/tie outoutsdie, invisible fenceoutsie, not containedOther
Where does your dog stay while you are NOT HOME?*

inside, with supervisioninside, free reininside, crateinside, contained to a room with baby gateoutside, fenced in yardoutside, on a calbe/tie outoutside, invisible fenceoutside, not containedOther
Where does your dog sleep at night?*
And does he sleep through the night?
Does your dog sleep through the night? If yes simply state Yes and if not please indicate if he needs to get up once or more.*
What is your dogs daily routine*
Between 7am - 12 pm
What is your dogs daily routine*
12 pm - 4pm
What is your dogs daily routine*
4pm - 10 pm
What is your dogs daily routine
Complete for later times
When do you feed your dog?*
What type of food do you feed?*
How much do you feed your dog?*
How much does your dog weight?*
Is your dog overweight?*
How often does your dog have a BM in a day*
How often does your dog have soft, runny or diarrea? Please specify how often like days, weeks or months.*
Does your dog get foraging toys or activities daily?*

YesNoNot daily
How often does your dog eat out of foraging toys? Like Kongs and or Toppl or Puzzle like toys?*
If the above answer was no, answer below with a no. Otherwise if yes , what type of foraging and enrichment does your dog partake in?*
Please describe what and how you use
Does your dog have any allergies and to what?*
Who exercises your dog?*
How many minutes a day do you:
Run your dog:*
Walk your dog:*
Where do you walk or run your dog?*
Play with your dog:*
What does that play look like?
Train your Dog?*
What does training look like with you and your dog?
Allow your dog to play on their own:*
What is your dog doing in between these activities?*
Life Style Questions
How often do you take your dog to the park?*

never1 to 2 times a week3 to 5 times a weekDailyOther
How many hours a day does your dog rest?*
Sleep, snooze, just relaxes?
What percentage is your dog calm on a daily basis?*

20%40%60%80%100%
Is there anything else I should know about your dog's lifestyle?*
Does your dog have any illnesses or injuries or chronic conditions?*
When was your dogs last visit to the veterinarian?*
Behaviour and Training
What is the problem behaviour you would like help with?*
When did this or these behaviour/s start?*
What have you tried to date to work with this issue? *
Does your dog respond to any of the following loud noises?*

ThunderFireworksGunshotsVehiclesOther noises like washing machinedishwasherNo
If your dog does your dog response to Noises what does it look like?*
If your dog responds to noises what does it look like?*

SalivateToiletHide/EscapeDestroyFreezePantPaceRefuse FoodRefuse treatsBark/growlLungeYawnChaseSnap/bite/reactTremble/shakeSeek out PeopleOther
What specifically triggers this response?
How often does your dog encounter them?*
If your dog responds to humans what does it look like?*

SalivateToiletHide/EscapeDestroyFreezePantPaceRefuse FoodRefuse treatsBark/growlLungeYawnChaseSnap/bite/reactTremble/shakeSeek out PeopleOther
Other typical reaction when seeing or meeting other people?*

tail waggingbarkinghair standing upcowering/hidingnot interestedjumpinginterested but does not approachfriendlygrowlingOther
What specifically triggers this response?*
How often does your dog encounter them?*
Have you ever been concerned about your dog's interactions with family or non-family members? If yes, please explain.*
If your dog responds to other dogs what does it look like?*

SalivateToiletHide/EscapeDestroyFreezePantPaceRefuse FoodRefuse treatsBark/growlLungeYawnChaseSnap/bite/reactTremble/shakeSeek out People
Other possible reactons when seeing or meeting other dogs?*

tail waggingbarkinggrowlinghair standing upnot interestedjumpinginterested, but does not approachfriendlyOther
What specifically triggers this response?*
How often does your dog encounter them?*
Has your dog bitten another dog? Please describe in detail if yes and if the other dog needed veterinary care.*
If you go near or touch your dog's food or dish when she is eating will she show teeth, snap, growl or freeze in place? If Yes, please explain more detail.*
If your dog has a toy or treasured object in her mouth and you try and take it away from her will she show teeth, snap, growl or freeze in place? If yes, please explain.*
If your dog is on a bed or furniture and you ask her to move or get off, will she show teeth, snap, growl or freeze in place? If yes, please explain?*
Has your dog bitten a person? Please describe in detail if yes.*
What is your foundation training history?*
Please list any and all training along with methods you have done to date.*
Which activities get your dog excited and which are calming?*
Check off any training methods you have used with your dog.*

Dog PsychologyVerbal Correctionsshock/e-collar/vibration collarPhysical correctionsclickerpraisetreatspostitive reinforcementchoke/prong collardominance/pack leaderOther
Please check all that apply to your dog.*

cutest everfriendlyoutgoingbarks excessivley insdiebarks excessively outsideaggressive with other dogsruns awaydoes not come when calleddestructive when owner homedestructive when aloneshy or fearful in new situationsshy or fearful with new peopleshy or fearful with children or babies/toddlerspulls on leashchewspushysteals food, objects, trashis generally pretty awesomedigsunderstands but does not obeyurinates or defecates in the houseguards food/objects/peopleprotectivejealoussuper smartwilling to learn
Check skills you would like to learn*

sitstaydownquietgivewaitleave-itloose leash walkinggo to mat or bedcomeoffeye contactfocus outsidepotty trainingtargetting with nosecrate training
Is there anything else you would like to share about you and or your dog.*
How many times a day or week does your dog get worried about things that results in growling, shaking, lunging, hiding?*
How many times a day or week does your dog chase or bark at squirrels/mailmen/delivery persons?*
How many times a day or week does your dog encounter something new?*
environment, person, object
How many times a day does your dog get positively reinforced?*
"I would love to help you and your dog. I only work with clients who are committed to using positive training and behaviour modification t to build new behaviours, want to provide enriching and calming activities and games to help their dog learn. I do not use tools like prong collars or shock collars as they simply are not positive teaching tools and do not help in my training and behaviour work. I want to work with your dogs brain and their emotions and always keep the focus on positive. I am happy to help if you are ready to transition to an alternative training methodology based on science, then I am the trainer/behaviour consultant for you. If you are ready to grab a treat pouch along with whatever makes your dog happy then this is the place for you. Good luck with your training journey as I truly want owners and dogs to have an amazing relationship!"*

Agree
Are you and your family ready to make real life changes that will help affect your dogs training and behaviour? Training and behaviour change does take time to have an effect, and you will want to consider right now that training is going to become part of your routine. Are you ready? If you are then I am so happy to be chosen to help you and I will be committed to you in you and your dogs learning.*

YesNO
The Process

Thank you for your time with our questionnaire. After filling out the questionnaire, I will review, it will be put into your file and we can schedule your consultation. Part of the assessment process includes a functional assessment which allows me to fully complete my assessment. I will send you the PDF form that has all the instructions. Please be aware the remainder of this behaviour assessment process will be done virtually. Behaviour Issues can be linked to physical issues and my behaviour assessment helps us determine that we ask that you let your veterinarian be involved in order to rule out any medical issues that could be the cause. Behaviour and medical issues can be closely linked. Annual check-ups do not always look for issues unless you specifically let your veterinarian know. ( Pain/discomfort can be linked behaviour issues, up to 80% of behaviour issues) The initial in-home consultation will take approximately 60 - sometimes 90 mins. After our first visit, I will put together a training plan to meet you and your dog’s behaviour goals which may or may not be adjusted depending what information is collected prior, during the first session and at each subsequent session as well as what is happening in between sessions while you are working with your dog. It is not uncommon for adjustments to be made.
Do you agree in getting your dogs health and medical check up?*

YesNo
Liability Waiver, Termination and Training Policies

Sylvia Koczerzuk will endeavor to create a safe, healthy environment for the training of my dog(s) and will offer only safe, ethical, responsible and scientifically-sound training suggestions and lifestyle recommendations. Sylvia Koczerzuk, CPDT, CDBC trains with science-based positive reinforcement techniques. I am a Force-Free Trainer I am informed by science, buided by empathy, governed by ethics! I expressly and voluntarily assume all risk of injury while training my dog(s). I recognize that while Sylvia Koczerzuk is responsible for the unintentional errors, omissions or incorrect assertions. I understand that the recommendation of any other product or service is not a guarantee of my satisfaction. Further, I am and will remain responsible for the actions of my dog at all times, and I hereby agree to indemnify and hold harmless Sylvia Koczerzuk and , of any and all claims of injury, expenses or damages caused by the actions of my dog while under Sylvia Koczerzuk instruction, the care of Sylvia Koczerzuk or under my own care as a result of following the training plan. I understand the inherent risks of owning a dog, including but not limited to, the risk of dog bites to other animals, other people or myself. I understand the behaviour of a moment-to-moment decision-making animal can never be guaranteed. Therefore, the success of my dog(s) is highly correlated to the amount of time I spend practicing the desired behaviours with my dog(s) and the degree of consistency family members and I employ. I realize that my success is contingent on my family’s dedication to working with our dog on a daily basis. There are no guarantees with behaviour modification, and I will not hold Sylvia Koczerzuk responsible if my dog does not meet our training goals.
The Client agrees to assume full legal, financial and moral responsibility for the actions of their pet(s). The Client further expressly waives any liability arising from the generally accepted canine training practices and procedures employed by Sylviia Koczerzuk of Walkabout Canine Consulting. The Client(s) agree that my/our heirs, assignees and legal representatives will not make claim against, sue, or attach the property of Sylvia Koczerzuk and Walkabout Canine Consulting, its owner, relatives of its owner, assigns, agents or representatives, acquaintances, or any other person acting on behalf of WCC (hereafter referred to as “Agents”), for injury or damage to or by pet(s) resulting from an act or omission, however caused, by Sylvia Koczerzuk and Walkabout Canine Consulting. of client(s) The Client(s) forever release Walkabout Canine Consulting and it’s Agents from any and all liability and demands which the Client(s), and their heirs, assignees and legal representatives may have or may hereafter have for injury or damage to or by pet(s), and assume all risks thereof.
Termination of Service: WCC is fully committed to providing Client(s) with the tools they need to forge a positive and lasting relationship with their pet and has devoted over 30 years of pet care and behavioural studies to achieve that goal. Occasionally, Clients do not provide the necessary degree of commitment to the training process to facilitate positive results. In those rare circumstances, the training is unlikely to succeed notwithstanding the best efforts of WCC. If, at the sole discretion of WCC, the Client(s) is found not to be committed to the work involved for behaviour change, WCC reserves the right to terminate the contract and refund any outstanding balances to the Client(s). If however the client chooses to discontinue services for no reason before completion date there will not no refunds for sessions purchased.
By checking the "I agree" box below, I have read and agree to the liability waiver terms and termination and training policies.*

I agree
Dispute Resolution:

The Client(s) and WCC hereby agree to mediate and/or arbitrate any misunderstandings that may arise pursuant to the terms contained herein. In any action or proceeding arising out of this agreement, the prevailing party reimbursement shall be limited to actual costs and expenses incurred.
Check Below*

I agree
Media Release Heading

By checking the "I agree" box below, I hereby give my full consent to all photographs, audio recordings, video recordings and/ or academic work taken of me, my dog(s), friends and family members (including minor children) by Sylvia Koczerzuk, or their designee. I understand that any such photographs, audio or video recordings, and academic work become the property of Sylvia Koczerzuk, and may be used without consent, for instructional, educational, or promotional purposes as determined by Sylvia Koczerzuk in broadcast and electronic media formats, now existing or in the future created.
Check below*

I agreeDo not agree
Release for Veterinary Information Purposes: Heading

The Client(s) agree to allow Sylvia Koczerzuk at Walkabout Canine Consutling to contact my pet’s veterinarian to discuss behaviour and medical history.
Check Below*

I agree
Cancellation Policy

By checking the "I agree" box below, I understand and agree to the following cancellation policy terms: 1. Once a training program has started, there are NO refunds. 2. The client may reschedule or cancel ONE prescheduled private session without penalty. Any subsequent reschedules or cancellations will count as and be charged as a prepaid session in the training plan. It is imperative that sessions be scheduled on a consistent basis and in a timely manner. 3. A minimum of 48 hours notice is required to cancel a scheduled session without penalty. 4. When a client chooses not to continue the remainder of the training session, there will be NO REFUNDS.
Agree*

Yes
Any prepaid in person sessions must be used within a period depending on the amount of sessions package paid for. 3 session prepaid must be used within 2 months and 6 prepaid session must be used within 3 months. Online/Hybrid programs that include in person will and can be replace with Virtual meeting at our discretion. Any sessions not pre-booked at time of last meeting will be up to the CLIENT/PAYEE to schedule and reschedule appointments except for the SA program which must be booked after each reassessment. This policy help both of us. Once you sign up there are NO REFUNDs.
Click to Agree*

Agree
Those participating in any group classes that miss a week will not be reimbursed nor given any compensation for any missing class.
Click Below*

I agree
Payment Policy

By checking the "I agree" box below, I understand and agree to the following payment policy: Payment via E-Transfer to walkaboutcanineconsulting@gmail.com is DUE IN FULL upon booking of services.
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I agree
Contract Review

By checking the "I agree" box below, this contract is validated, and approval for future services without additional written authorization. I have read and agree to the terms of this contract and Policies. I also understand that the desired outcomes for my dog’s training and behaviour is directly proportional to the time, commitment and positive reinforcement technique spent working with my dog in between training sessions.
CHECK BELOW

I agree
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Behaviour Assessment Consultation Form

Life Style Questions

Behaviour and Training

The Process

Liability Waiver, Termination and Training Policies

Dispute Resolution:

Media Release Heading

Release for Veterinary Information Purposes: Heading

Cancellation Policy

Payment Policy

Contract Review