Pre-Consultation History Questionnaire

1
Invoice ID
2
Your Name* This field is required.
First Name
Last Name
3
Your Email* This field is required.This is where the copy of the completed form will be sent.
example@example.com
4
Your Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Equine's Address
Facility Name
Street Address
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Equine's Information
Equine's Name
Species/Breed
Color
Please Select
Please Select
Male
Male (Castrated)
Female
Female (Ovariectomy)
Neither (e.g. Hermaphroditic)
Sex
Equine's Date of Birth (DD/MO/YYYY)
7
Veterinarian's InformationNote: I typically reach out to your veterinarian prior to the consult to ensure they feel potential elements of pain are being adequately addressed (or eliminated) and a behavioral modification plan can be started. On the next page, you will have the option of uploading medical records for the horse.
Veterinarian Name (First & Last)
Veterinary Practice Name (If Applicable)
Veterinarian or Veterinary Practice Email
Veterinarian or Veterinary Practice Phone Number
When was the equine last assessed by this veterinarian?
Are there any current or past medical conditions or injuries that you feel may affect your horse's behavior?
8
Equine's Medical RecordsThis field is optional. Records are best uploaded in PDF Form.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
9
Other Equine ProfesssionalsSelect all other types of equine professionals which you regularly employ or who have seen your horse in the last 6 months.
Dentist
Farrier
Saddle Fitter
Trainer
Osteopath
Physiotherapist
Chiropractor
Reiki Practitioner
Animal Communicator
Behaviorist
Other
10
How Did You Obtain This Horse?
Purchased/Gifted/AdoptedHad Since Birth
11
When Did You Obtain This Horse?What date did this horse enter your care?
Date
Year
Month
Day
12
How Long Has the Horse Been in its Current Location?
13
Is this a Feral or Wild Horse Obtained Directly from the Managing Agency?Managing agencies include (but are not limited to): Bureau of Land Management, Forest Service
YESNO
14
Wild/Feral Horse History
Managing Agency
Gather Date
Location of equine while feral (e.g. Herd Management Area Name)
# of Facilities Housed at (If Known)
# of Previous Adopters (if any)
Most Recent Facility Name
Date of Pickup
15
Purchase History
Reason for purchase or ownership of horse?
Number of previous owners?
Previous uses for the horse?
Previous owner's stated reason for selling the horse?
Any known accidents or injuries sustained with previous owner(s)?
16
Prior Living ConditionsDescribe the stabling or pasture situation for the horse prior to its arrival with you (if known). Did it have access to other horses without a physical barrier between them? Was it boarded in a stall with turnout? Was it fed limited meals or did it have access to 24/7 forage?
Huge
Large
Normal
Small
Ok
Ok
17
Training HistoryWhat methods were used to train this horse prior to its arrival with you? Choose all that you feel apply.
Pressure/Release (e.g. lunging with a whip)
Clicker Training (using a marker when a wanted behavior is given and following with food or scratch)
Scratches as a Reward
Natural Horsemanship
Food as a Reward
Positive Reinforcement (adding food or scratches when a wanted behavior is given)
Negative Reinforcement (e.g. pressure on reins to ask for a back)
Positive Punishment (e.g. using a whip if a horse does not go forward)
Negative Punishment (e.g. taking a meal away during unwanted behavior)
Verbal Praise as a Reward
Escalating Pressure (e.g. kicking harder if a horse does not go forward)
Other
18
Human Contact AgeAt what age did the horse first have contact with humans in a domestic environment? (Write "Unknown" if not known)
19
Do You Know the Weaning History for this Equine?
YESNO
20
Was this Equine Rejected as a Foal or an Orphan?
YESNO
21
Foal's Access to Other EquinesSelect all genders and age-groups that foal had access to prior to weaning.
Stallion(s)
Gelding(s)
Mare(s) [Aside from dam]
Male Foals
Female Foals
No Access Aside from Dam
Other
22
Age the Equine First had Contact with other Equines?(Aside from the dam)
23
What Age Was the Foal Weaned?
24
Provide a Brief Description of the Weaning Process(e.g. Mare and foal separated by a fence, but foal was still able to nurse through fence. Foal was housed with 5 other foals in a mixed gender group during this period. After 2 months, the mare was moved to a paddock where the mare and foal could not physically interact.)
Huge
Large
Normal
Small
Ok
Ok
25
DietIf horse has access to grazing, please include a row for grazing.
Food Type & Container (e.g. grass hay in 1" opening hay net)
Amount
# Times Given Per Day
How Quickly is it Eaten
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
6
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
7
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
8
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
1
2
3
4
5
6
7
8
Food Type & Container (e.g. grass hay in 1" opening hay net)
Row 0, Column 0
Amount
Row 0, Column 1
# Times Given Per Day
Row 0, Column 2
How Quickly is it Eaten
Row 0, Column 3
Food Type & Container (e.g. grass hay in 1" opening hay net)
Row 1, Column 0
Amount
Row 1, Column 1
# Times Given Per Day
Row 1, Column 2
How Quickly is it Eaten
Row 1, Column 3
Food Type & Container (e.g. grass hay in 1" opening hay net)
Row 2, Column 0
Amount
Row 2, Column 1
# Times Given Per Day
Row 2, Column 2
How Quickly is it Eaten
Row 2, Column 3
Food Type & Container (e.g. grass hay in 1" opening hay net)
Row 3, Column 0
Amount
Row 3, Column 1
# Times Given Per Day
Row 3, Column 2
How Quickly is it Eaten
Row 3, Column 3
Food Type & Container (e.g. grass hay in 1" opening hay net)
Row 4, Column 0
Amount
Row 4, Column 1
# Times Given Per Day
Row 4, Column 2
How Quickly is it Eaten
Row 4, Column 3
Food Type & Container (e.g. grass hay in 1" opening hay net)
Row 5, Column 0
Amount
Row 5, Column 1
# Times Given Per Day
Row 5, Column 2
How Quickly is it Eaten
Row 5, Column 3
Food Type & Container (e.g. grass hay in 1" opening hay net)
Row 6, Column 0
Amount
Row 6, Column 1
# Times Given Per Day
Row 6, Column 2
How Quickly is it Eaten
Row 6, Column 3
Food Type & Container (e.g. grass hay in 1" opening hay net)
Row 7, Column 0
Amount
Row 7, Column 1
# Times Given Per Day
Row 7, Column 2
How Quickly is it Eaten
Row 7, Column 3
1 of 8
26
Medications & Supplements
Supplement Type
How Often Given?
What Food is this Given With?
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
6
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
1
2
3
4
5
6
Supplement Type
Row 0, Column 0
How Often Given?
Row 0, Column 1
What Food is this Given With?
Row 0, Column 2
Supplement Type
Row 1, Column 0
How Often Given?
Row 1, Column 1
What Food is this Given With?
Row 1, Column 2
Supplement Type
Row 2, Column 0
How Often Given?
Row 2, Column 1
What Food is this Given With?
Row 2, Column 2
Supplement Type
Row 3, Column 0
How Often Given?
Row 3, Column 1
What Food is this Given With?
Row 3, Column 2
Supplement Type
Row 4, Column 0
How Often Given?
Row 4, Column 1
What Food is this Given With?
Row 4, Column 2
Supplement Type
Row 5, Column 0
How Often Given?
Row 5, Column 1
What Food is this Given With?
Row 5, Column 2
1 of 6
27
Does your equine receive any other food?Describe this additional source of food (brand, type), the amount (e.g. a few handfuls), and the context in which it is given (e.g. training sessions, hand-fed treats, enrichment items)
Huge
Large
Normal
Small
Ok
Ok
28
Describe your equine's access to waterPlease include details such as when the horse has access to water, how many water sources there are, the quantity of water, and the type of container the water is provided in.
Huge
Large
Normal
Small
Ok
Ok
29
Is there anything else you'd like to add about forage?If there is anything in relation to forage that you felt should have been included in the previous questions, but you were not able to discuss, please include that here. Explain in as much detail as you would like.
Huge
Large
Normal
Small
Ok
Ok
30
Daily HousingPlease list the locations and environment types your equine experiences throughout a typical day. Type (e.g. stall) Size (e.g. 12' x 12' or 1 acre) Time of Day (e.g. 6 AM to 8 AM)
Type (e.g. stall)
Size
Time of Day (e.g. 6 AM to 8 AM)
Access to Other Equines?
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
No
Yes, with a physical barrier between them
Yes, other equines in the same space
Row 0, Column 3
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
No
Yes, with a physical barrier between them
Yes, other equines in the same space
Row 1, Column 3
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
No
Yes, with a physical barrier between them
Yes, other equines in the same space
Row 2, Column 3
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
No
Yes, with a physical barrier between them
Yes, other equines in the same space
Row 3, Column 3
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
No
Yes, with a physical barrier between them
Yes, other equines in the same space
Row 4, Column 3
6
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
No
Yes, with a physical barrier between them
Yes, other equines in the same space
Row 5, Column 3
1
2
3
4
5
6
Type (e.g. stall)
Row 0, Column 0
Size
Row 0, Column 1
Time of Day (e.g. 6 AM to 8 AM)
Row 0, Column 2
Access to Other Equines?
No
Yes, with a physical barrier between them
Yes, other equines in the same space
Row 0, Column 3
Type (e.g. stall)
Row 1, Column 0
Size
Row 1, Column 1
Time of Day (e.g. 6 AM to 8 AM)
Row 1, Column 2
Access to Other Equines?
No
Yes, with a physical barrier between them
Yes, other equines in the same space
Row 1, Column 3
Type (e.g. stall)
Row 2, Column 0
Size
Row 2, Column 1
Time of Day (e.g. 6 AM to 8 AM)
Row 2, Column 2
Access to Other Equines?
No
Yes, with a physical barrier between them
Yes, other equines in the same space
Row 2, Column 3
Type (e.g. stall)
Row 3, Column 0
Size
Row 3, Column 1
Time of Day (e.g. 6 AM to 8 AM)
Row 3, Column 2
Access to Other Equines?
No
Yes, with a physical barrier between them
Yes, other equines in the same space
Row 3, Column 3
Type (e.g. stall)
Row 4, Column 0
Size
Row 4, Column 1
Time of Day (e.g. 6 AM to 8 AM)
Row 4, Column 2
Access to Other Equines?
No
Yes, with a physical barrier between them
Yes, other equines in the same space
Row 4, Column 3
Type (e.g. stall)
Row 5, Column 0
Size
Row 5, Column 1
Time of Day (e.g. 6 AM to 8 AM)
Row 5, Column 2
Access to Other Equines?
No
Yes, with a physical barrier between them
Yes, other equines in the same space
Row 5, Column 3
1 of 6
31
Other EquinesThis question shows if you answered "yes" to "Access to Other Equines" in the previous question. It is designed to get a general idea of your equine's relationships with others.
Name
Species/Breed
Age
Sex
Your Horse's Behavior When Listed is Removed
Duration of Behavior
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 0, Column 3
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 0, Column 4
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 0, Column 5
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 1, Column 3
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 1, Column 4
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 1, Column 5
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 2, Column 3
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 2, Column 4
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 2, Column 5
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 3, Column 3
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 3, Column 4
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 3, Column 5
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 4, Column 3
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 4, Column 4
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 4, Column 5
6
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 5, Column 3
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 5, Column 4
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 5, Column 5
7
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 6, Column 3
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 6, Column 4
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 6, Column 5
8
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 7, Column 3
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 7, Column 4
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 7, Column 5
9
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 8, Column 3
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 8, Column 4
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 8, Column 5
10
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 9, Column 3
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 9, Column 4
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 9, Column 5
1
2
3
4
5
6
7
8
9
10
Name
Row 0, Column 0
Species/Breed
Row 0, Column 1
Age
Row 0, Column 2
Sex
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 0, Column 3
Your Horse's Behavior When Listed is Removed
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 0, Column 4
Duration of Behavior
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 0, Column 5
Name
Row 1, Column 0
Species/Breed
Row 1, Column 1
Age
Row 1, Column 2
Sex
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 1, Column 3
Your Horse's Behavior When Listed is Removed
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 1, Column 4
Duration of Behavior
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 1, Column 5
Name
Row 2, Column 0
Species/Breed
Row 2, Column 1
Age
Row 2, Column 2
Sex
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 2, Column 3
Your Horse's Behavior When Listed is Removed
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 2, Column 4
Duration of Behavior
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 2, Column 5
Name
Row 3, Column 0
Species/Breed
Row 3, Column 1
Age
Row 3, Column 2
Sex
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 3, Column 3
Your Horse's Behavior When Listed is Removed
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 3, Column 4
Duration of Behavior
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 3, Column 5
Name
Row 4, Column 0
Species/Breed
Row 4, Column 1
Age
Row 4, Column 2
Sex
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 4, Column 3
Your Horse's Behavior When Listed is Removed
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 4, Column 4
Duration of Behavior
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 4, Column 5
Name
Row 5, Column 0
Species/Breed
Row 5, Column 1
Age
Row 5, Column 2
Sex
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 5, Column 3
Your Horse's Behavior When Listed is Removed
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 5, Column 4
Duration of Behavior
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 5, Column 5
Name
Row 6, Column 0
Species/Breed
Row 6, Column 1
Age
Row 6, Column 2
Sex
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 6, Column 3
Your Horse's Behavior When Listed is Removed
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 6, Column 4
Duration of Behavior
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 6, Column 5
Name
Row 7, Column 0
Species/Breed
Row 7, Column 1
Age
Row 7, Column 2
Sex
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 7, Column 3
Your Horse's Behavior When Listed is Removed
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 7, Column 4
Duration of Behavior
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 7, Column 5
Name
Row 8, Column 0
Species/Breed
Row 8, Column 1
Age
Row 8, Column 2
Sex
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 8, Column 3
Your Horse's Behavior When Listed is Removed
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 8, Column 4
Duration of Behavior
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 8, Column 5
Name
Row 9, Column 0
Species/Breed
Row 9, Column 1
Age
Row 9, Column 2
Sex
Stallion
Gelding
Mare
Mare (Ovariectomy)
Neither (e.g. Hermaphroditic)
Row 9, Column 3
Your Horse's Behavior When Listed is Removed
No reaction
Minor reaction (e.g. lifts head, may follow partway)
Some reaction (e.g. follows to the gate)
Strong reaction (whinnies and paces)
Panic (runs, calls out, bucking, jumps fences, etc.)
Row 9, Column 4
Duration of Behavior
A few seconds (< 1 min)
A few minutes
Several minutes
An hour
Several hours
Until removed equine is returned
Row 9, Column 5
1 of 10
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Describe Your Equine's Behavior Towards Other EquinesDo they chase or kick other horses? Do they avoid other horses? Do they instigate play with other horses? Etc.
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Ok
Ok
33
Describe the Behavior of Other Equines Towards Your HorseDo they chase or kick your equine? Do they avoid them? Do they instigate play? Etc.
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Small
Ok
Ok
34
Equine's Living SpaceWhat does your equine's living space look like? Physical barriers (fences, walls), gate locations, feed room locations, feeding stations, water locations, other equines (if any), etc.
Upload VideoProvide a Sketch
35
Living Space Video URLDue to file size restrictions, the easiest way to share videos is to upload it onto a video hosting website, such as Youtube, and post the link to the video below. If this option does not work for you, please note so in the box below and/or email me at sam@equineabcs.com and we will find a solution that works best for you.
36
Please Sketch Your Equine's Living SpacesInclude physical barriers (fences, walls), gate locations, feed room locations, feeding stations, water locations, general locations of other equines (if any)
Upload SketchSketch Directly on Screen
37
Upload a Drawing of Your Equine's Living SpacesInclude physical barriers (fences, walls), gate locations, feed room locations, feeding stations, water locations, general locations of other equines (if any)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
38
Sketch Your Equine's Living Spaces in the Field BelowInclude physical barriers (fences, walls), gate locations, feed room locations, feeding stations, water locations, general locations of other equines (if any)
39
Who is the Horse Regularly Handled By?Select options according to a normal day. Choose as many as you feel apply.
Yourself
Groom
Trainer
Barn Staff
Students (> 18 y.o.)
Students (13-18 y.o.)
Students (< 13 y.o.)
Family Member (> 18 y.o.)
Friend (> 18 y.o.)
Family Member (13-18 y.o.)
Friend (13-18 y.o.)
Family Member (< 13 y.o.)
Friend (< 13 y.o.)
Other
40
Rate Your Equine's Husbandry SkillsetHow well do you feel your equine performs the following tasks?
Without Hesitation
With Hesitation (e.g. head raise)
Unwanted Behaviors (e.g. fidgeting)
Agonistic Behaviors (e.g. Biting)
Does not Perform
Leading
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Tying (Ground Tie)
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Tying (Pole/Cross-tie)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Hoof Cleaning
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Grooming
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Bathing
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Loading into Trailer
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Worming
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Clipping
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Veterinary Exams
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Leading
Tying (Ground Tie)
Tying (Pole/Cross-tie)
Hoof Cleaning
Grooming
Bathing
Loading into Trailer
Worming
Clipping
Veterinary Exams
Without Hesitation
Row 0, Column 0
With Hesitation (e.g. head raise)
Row 0, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 0, Column 2
Agonistic Behaviors (e.g. Biting)
Row 0, Column 3
Does not Perform
Row 0, Column 4
Without Hesitation
Row 1, Column 0
With Hesitation (e.g. head raise)
Row 1, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 1, Column 2
Agonistic Behaviors (e.g. Biting)
Row 1, Column 3
Does not Perform
Row 1, Column 4
Without Hesitation
Row 2, Column 0
With Hesitation (e.g. head raise)
Row 2, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 2, Column 2
Agonistic Behaviors (e.g. Biting)
Row 2, Column 3
Does not Perform
Row 2, Column 4
Without Hesitation
Row 3, Column 0
With Hesitation (e.g. head raise)
Row 3, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 3, Column 2
Agonistic Behaviors (e.g. Biting)
Row 3, Column 3
Does not Perform
Row 3, Column 4
Without Hesitation
Row 4, Column 0
With Hesitation (e.g. head raise)
Row 4, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 4, Column 2
Agonistic Behaviors (e.g. Biting)
Row 4, Column 3
Does not Perform
Row 4, Column 4
Without Hesitation
Row 5, Column 0
With Hesitation (e.g. head raise)
Row 5, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 5, Column 2
Agonistic Behaviors (e.g. Biting)
Row 5, Column 3
Does not Perform
Row 5, Column 4
Without Hesitation
Row 6, Column 0
With Hesitation (e.g. head raise)
Row 6, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 6, Column 2
Agonistic Behaviors (e.g. Biting)
Row 6, Column 3
Does not Perform
Row 6, Column 4
Without Hesitation
Row 7, Column 0
With Hesitation (e.g. head raise)
Row 7, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 7, Column 2
Agonistic Behaviors (e.g. Biting)
Row 7, Column 3
Does not Perform
Row 7, Column 4
Without Hesitation
Row 8, Column 0
With Hesitation (e.g. head raise)
Row 8, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 8, Column 2
Agonistic Behaviors (e.g. Biting)
Row 8, Column 3
Does not Perform
Row 8, Column 4
Without Hesitation
Row 9, Column 0
With Hesitation (e.g. head raise)
Row 9, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 9, Column 2
Agonistic Behaviors (e.g. Biting)
Row 9, Column 3
Does not Perform
Row 9, Column 4
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Current TrainingWhat methods are used when training and/or handling this horse? Choose all that you feel apply.
Pressure/Release
Clicker Training
Scratches as a Reward
Natural Horsemanship
Food as a Reward
Positive Reinforcement
Negative Reinforcement
Positive Punishment
Negative Punishment
Verbal Praise as a Reward
Escalating Pressure
Other
42
Do You Ride this Equine?Choose "yes" even if you recently stopped riding your equine.
YESNO
43
Date Last Ridden
Date
Year
Month
Day
44
Riding DisciplineSelect all that apply
Classical Dressage
Reining
Show Jumping
Cutting
Eventing
Barrel Racing
Endurance
Western Dressage
Driving
Trail Riding
Packing (Backcountry)
Ranch Horse (e.g. working Cattle)
Western
English
Other
45
TackBriefly describe your equine's tack - include bridle type, bit type(s), saddle type(s), and any additional equipment you use. If you have a saddle-fitter out for your horse, please include the date of the last saddle fit.
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Large
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Small
Ok
Ok
46
Rate Your Equine's Riding SkillsetsHow well do you feel your equine performs the following tasks?
Without Hesitation
With Hesitation (e.g. head raise)
Unwanted Behaviors (e.g. fidgeting)
Agonistic Behaviors (e.g. Biting)
Does not Perform
Bridling
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Accepting Saddle Blanket
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Accepting Saddle
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Standing for Mounting
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Walk
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Trot (or Gait)
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Canter (or Gallop)
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Slowing Down
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Stop
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Bridling
Accepting Saddle Blanket
Accepting Saddle
Standing for Mounting
Walk
Trot (or Gait)
Canter (or Gallop)
Slowing Down
Stop
Without Hesitation
Row 0, Column 0
With Hesitation (e.g. head raise)
Row 0, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 0, Column 2
Agonistic Behaviors (e.g. Biting)
Row 0, Column 3
Does not Perform
Row 0, Column 4
Without Hesitation
Row 1, Column 0
With Hesitation (e.g. head raise)
Row 1, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 1, Column 2
Agonistic Behaviors (e.g. Biting)
Row 1, Column 3
Does not Perform
Row 1, Column 4
Without Hesitation
Row 2, Column 0
With Hesitation (e.g. head raise)
Row 2, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 2, Column 2
Agonistic Behaviors (e.g. Biting)
Row 2, Column 3
Does not Perform
Row 2, Column 4
Without Hesitation
Row 3, Column 0
With Hesitation (e.g. head raise)
Row 3, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 3, Column 2
Agonistic Behaviors (e.g. Biting)
Row 3, Column 3
Does not Perform
Row 3, Column 4
Without Hesitation
Row 4, Column 0
With Hesitation (e.g. head raise)
Row 4, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 4, Column 2
Agonistic Behaviors (e.g. Biting)
Row 4, Column 3
Does not Perform
Row 4, Column 4
Without Hesitation
Row 5, Column 0
With Hesitation (e.g. head raise)
Row 5, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 5, Column 2
Agonistic Behaviors (e.g. Biting)
Row 5, Column 3
Does not Perform
Row 5, Column 4
Without Hesitation
Row 6, Column 0
With Hesitation (e.g. head raise)
Row 6, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 6, Column 2
Agonistic Behaviors (e.g. Biting)
Row 6, Column 3
Does not Perform
Row 6, Column 4
Without Hesitation
Row 7, Column 0
With Hesitation (e.g. head raise)
Row 7, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 7, Column 2
Agonistic Behaviors (e.g. Biting)
Row 7, Column 3
Does not Perform
Row 7, Column 4
Without Hesitation
Row 8, Column 0
With Hesitation (e.g. head raise)
Row 8, Column 1
Unwanted Behaviors (e.g. fidgeting)
Row 8, Column 2
Agonistic Behaviors (e.g. Biting)
Row 8, Column 3
Does not Perform
Row 8, Column 4
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47
Riding Schedule
How many days a week is this horse ridden?
How long is this horse ridden for during an average session?
Who normally rides the horse?
Is this horse ridden by another rider (such as a trainer, friend, or lessee?)
48
Your Goals for Your EquineWhat are the goals and expectations you have for your equine? An example is training an equine to compete in 100 mile endurance races. Another is a retired equine who is meant to provide companionship to another equine on the property.
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Ok
Ok
49
Description of Problem BehaviorWhat is the main, target behavioral problem that you would like to see resolved?
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Ok
50
Do you already have video of this behavior?IMPORTANT: Do not try and replicate the behavior as this can make it harder to treat and it may be extremely dangerous! If you do not have a video, do not make one.
YESNO
51
Problem Behavior Video URLIMPORTANT: Do not try and replicate the behavior as this can make it harder to treat and it may be extremely dangerous! If you do not have a video, do not make one. Due to file size restrictions, the easiest way to share videos is to upload it onto a video hosting website, such as Youtube, and post the link to the video below. If this option does not work for you, please note so in the box below and/or email me at sam@equineabcs.com and we will find a solution that works best for you.
52
Location of Problem BehaviorInclude physical barriers (fences, walls), gate locations, feed room locations, feeding stations, water locations, general locations of other equines (if any)
Provide VideoProvide Sketch
53
Video URL of Location of Problem Behavior Due to file size restrictions, the easiest way to share videos is to upload it onto a video hosting website, such as Youtube, and post the link to the video below. If this option does not work for you, please note so in the box below and/or email me at sam@equineabcs.com and we will find a solution that works best for you.
54
Sketch Location of Problem BehaviorInclude physical barriers (fences, walls), gate locations, feed room locations, feeding stations, water locations, general locations of other equines (if any)
Upload SketchSketch Directly on Screen
55
Upload a Drawing of Problem Behavior LocationInclude physical barriers (fences, walls), gate locations, feed room locations, feeding stations, water locations, general locations of other equines (if any)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
56
Sketch The Location of the Problem Behavior in the Field BelowInclude physical barriers (fences, walls), gate locations, feed room locations, feeding stations, water locations, general locations of other equines (if any)
57
When did you first notice this specific behavioral issue?
58
How would you describe the onset of the behavior?
Please Select
Please Select
Sudden (overnight or a few days)
Gradual (over several weeks)
Slow (over several months)
Very slow (several years)
59
Horses Attitude Surrounding Problem BehaviorSlide the emoji left and right to best describe the horse's attitude during the problem behavior.
Before
During
After
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6
Row 1, Column 0Row 1, Column 1Row 1, Column 2Row 1, Column 3Row 1, Column 4Row 1, Column 5Row 1, Column 6
Row 2, Column 0Row 2, Column 1Row 2, Column 2Row 2, Column 3Row 2, Column 4Row 2, Column 5Row 2, Column 6
Before
During
After
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6
Row 1, Column 0Row 1, Column 1Row 1, Column 2Row 1, Column 3Row 1, Column 4Row 1, Column 5Row 1, Column 6
Row 2, Column 0Row 2, Column 1Row 2, Column 2Row 2, Column 3Row 2, Column 4Row 2, Column 5Row 2, Column 6
60
How Frequent is the Problem Behavior?
61
Is the Behavior Individual-Specific?Does the problem occur only with specific handlers or with specific equines/other animals? If so, who does it occur with?
62
Describe the First Instance of the Problem BehaviorInclude things such as time of day, weather, equipment being used (if any), other horses, behaviors immediately proceeding and immediately following by the horse, and/or actions of humans or other animals involved. You may include URL links to drawings and/or images or videos if they are safe to obtain or are already obtained. Use as much space or email (sam@equineabcs.com) as many additional documents as needed.
Huge
Large
Normal
Small
Ok
Ok
63
Development of Problem BehaviorHow would you describe the change in severity of the problem behavior since its first occurrence?
Great improvement
Mildly worse
Moderate improvement
Moderately worse
Mild improvement
Much worse
No change
Other
64
Describe Most Recent Occurrence of Problem BehaviorInclude things such as time of day, weather, equipment being used (if any), other horses, behaviors immediately proceeding and immediately following by the horse, and/or actions of humans or other animals involved. You may include URL links to drawings and/or images or videos if they are safe to obtain or are already obtained. Use as much space or email (sam@equineabcs.com) as many additional documents as needed.
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Small
Ok
Ok
65
Ideal Behavior* This field is required.What is your ideal result for a behavioral treatment of this problem behavior? (In other words, what criteria would you use to determine that treatment was a success and the problem is either solved or addressed as thoroughly as you would like?)
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Ok
66
Attempted SolutionsHave you (or others) attempted to solve the problem? If so, how?
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Ok
Ok
67
Additional Problem Behavior InformationUse this text box if you would like to include any additional information about the behavior or related to the behavior that you believe is important or relevant.
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Ok
Ok
68
Questions?Write any questions you have for me. This will allow me to be better prepared for answering these questions and related ones. We can discuss them during the consultation.
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Ok
Ok
69
Rate the Form
1
2
3
4
5
Worst Rating
Best Rating
70
Feedback - How Can It Be Improved?Please type your recommendations for how to improve the form below. This document is under regular adjustment and review using client feedback. I really appreciate your thoughts!
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Ok
Should be Empty: