Service Dog Consultation Intake Form

Service Dog Consultation Intake Form
Full Name
Phone Number
Email Address
example@example.com
Emergency Contact
Name
Relationship
Phone Number
Service Dog Candidate Information:
Dogs Name
BreedMix
Age
Weight
Does your dog have any previous training? If Yes please describe
Spayed/Neutered?
How long have you had your dog
Dogs Health and Behavior:
Veterinarians Name
Veterinarian's Phone Number
Date of Last Vet Visit

MonthDayYear
Date
Is you dog up to date on Vaccinations

yesno
Current Medications if any
Does your dog have a history of serious behavior problems (e.g., fear, separation anxiety)?If yes, please describe:
Service Dog Needs and Goals:
Primary tasks you need the service dog to perform:

Mobility AssistanceMedical AlertAutism SupportSupport Hearing AssistanceOther
Please describe the specific tasks you need the dog to perform
How long are you able to commit to the training process?

3 months6 months1 year2 yearsAs long as necessary
Are you able to practice with your dog regularly between appointments?
Do you have any previous experience working with service dogs?

YesNo
Why are you interested in a service dog
Is there anything else you would like us to know
Acknowledgment: By signing below, I acknowledge that the information provided is accurate and truthful to the best of my knowledge. I understand that the training process requires a significant commitment of time and effort.
Client Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Emergency Contact