Trainer Referral
To be complete only by a qualified trainer referring a client to BYVH for behavior support/extended behavior consultation
Your Name
*
First Name
Last Name
Business Name if Applicable
Your E-mail
*
example@example.com
Client Name
*
First Name
Last Name
Animal's Name
*
Please provide a brief behavior summary and areas where pharmacologic intervention may help:
*
*While a trainer is an expert in behavior observation and formulating a behavior modification plan, a trainer is not qualified to make suggestions or recommendations about specific medications.
How long have you been working with this patient/client? Do they have plans for continued training?
*
Any other info we should know? Would you consider this case to need more immediate attention?
Does this patient have a bite history? What level? In the case of human-directed bites, we would strongly recommend referral to a DACVB.
*
Have you suggested/recommended a consult with Animal Behavior Clinic or Synergy for consultation with a Diplomat of the American College of Veterinary Behavior (DACVB)?
*
Please Select
YES
NO
Please indicate why (if known) the client has opted not to consult with a DACVB or why this option was not recommended.
*
I have reiterated to the client that they will need to transfer ALL veterinary care to Brooklyn Yard Veterinary Hospital, as we do not operate as a referral facility. If the client transfers care at any point, we will no longer be able to provide medication refills or adjustments. If the client wishes to remain with their current veterinarian, both Animal Behavior Clinic and Synergy offer vet-to-vet consults (for a fee) with any veterinarian.
*
Please Select
YES
NO
If you have selected NO, we will follow-up with client to ensure that our policy is clear.
If you use your own assessment forms/summary, please upload here!
Cancel
of
Thank you so much for your referral!
Feel free to call or
email
us with any questions or additional information.
Submit
Should be Empty: