Behavioral Modification Package Questionnaire

Behavioural Modification Package Questionnaire

Thank you for choosing Millie's Marvellous Mutts! Please complete the form below so we can create a personalised behavioural modification plan for your dog.
Your Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Please enter a valid phone number.
Email
example@example.com

About Your Dog
Name
Breed
Age
Sex

MaleFemale
Is your dog neutered/spayed?

YesNo
How long have you had your dog?

Behavioral Concerns
What specific behaviors would you like to modify? (e.g., aggression, separation anxiety, excessive barking, chewing, digging, fear of certain noises)
How severe do you feel these behaviors are?

MildModerateSevere
Have these behaviors been consistent, or have they changed over time? (If they have changed, please explain how and when the changes occurred.)

Behavior Timeline
When did you first notice these behaviors?
Have these behaviors worsened, improved, or remained the same since you first noticed them?

Identifying Triggers
Are there specific situations or triggers that lead to these behaviors? (e.g., certain noises, strangers, other animals, being left alone, specific places or times of day)
Do you notice these behaviors more often in certain environments?

At homeOn walksAt the parkAround other animalsAround strangersOther

Professional Consultation
Have you consulted with a veterinarian or a certified behaviorist regarding these behavioral issues?

YesNo
If yes, what was their advice or recommended treatment plan? (Please include any medication, behavior modification techniques, or training methods suggested.)
Has your veterinarian ruled out any medical causes for these behaviors?

YesNoNot sureOther

Previous Attempts
What training methods or techniques have you tried in the past to address these behaviors? (e.g., positive reinforcement, aversive methods, obedience training, crate training, calming aids, etc.)
What results did you see from these methods?

No improvementMild improvementSignificant improvementWorsened the behaviourOther
What do you think has worked well, if anything?
What hasn’t worked, or has caused further issues?
Additional Information
Is there anything else you’d like to share about your dog’s behavior or history that may help with the modification plan?

Agreement
By submitting this form, you confirm that the information provided is accurate and complete to the best of your knowledge. This will help us create an effective behavioral modification plan tailored to your dog’s needs.
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Name

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My Products

Behavioural Modification Package

Includes: Customized training plans focused on specific behavioral challenges (e.g., aggression, anxiety). Duration: 6-8 weeks, depending on the issues. Follow-Up: Weekly check-ins and progress assessments. Ideal For: Dogs with behavioral issues requiring more attention and time.

£100.00

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£0.00

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Behavioural Modification Package Questionnaire

Your Information

About Your Dog

Behavioral Concerns

Behavior Timeline

Identifying Triggers

Professional Consultation

Previous Attempts

Additional Information

Agreement