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
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:
Mobility AssistanceMedical AlertAutism SupportSupport Hearing AssistanceOther
Please describe the specific tasks you need the dog to perform
3 months6 months1 year2 yearsAs long as necessary
Are you able to practice with your dog regularly between appointments?
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
Date

MonthDayYear
Date
Should be Empty:

Emergency Contact