Talking Pet Behaviour – Separation-Related Behaviour Assessment Form 1

Separation-Related Behaviour (SRB) Assessment Form

Section 1 - Owner & Dog Details

Section 2 - Background Information

Section 3 - Behaviour When Left Alone

Section 4 - Pre-Departure & Contextual Cues

Section 5 - Behaviour When You Are Home

Section 6 - Rule-Outs and Co-existing Issues

Section 7 - Owner Observations

Section 8 - Severity & Impact

Section 9 - Video / Recording Upload (optional)

Section 10 - Veterinary Information

Section 11 - Consent

(CLINICIAN USE ONLY)

Separation-Related Behaviour (SRB) Assessment Form

Please could you fill in this questionnaire as accurately as possible so that I can better understand your dog's problem behaviours.
Date

MonthDayYear
Date
Section 1 - Owner & Dog Details
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Pets name*
Breed / cross: Sex & neuter status:*

BreedNeutered or not Neutered
Date of Birth:

DayMonthYear
Date
Name of your Vet Practice*
Veterinary practice contact email*
example@example.com
Section 2 - Background Information
How long has your dog lived with you?*
Age at acquisition*
Date of last veterinary checkup*

MonthDayYear
Date
What food is s/he fed on?*
Any known medical conditions or pain history*
Household Composition - Who else lives in your house and what other pets, if any, do you have?*
Typical daily routine - Please describe your routine and include your working hours, walks, feeding and alone time schedule:*
Section 3 - Behaviour When Left Alone

Thinking about the recent past (last 1-3 months), how often has your dog shown the following behaviours when left alone?*

	Never	Rarely	Sometimes	Usually	Always	Unsure
Vocalises (whines/barks/howls)
Restless / paces / cannot settle
Pants, shakes or trembles
Scratches or jumps atdoors/windows
Destroys household items
Toilets Indoors
Drools, vomits or salivates
Ignores food or treats left out
Excessive greetings or frantic behaviour on your return
Attempts to escape (eg. break out of crate / injure self)

Do these behaviours happen every time your dog is left alone?*

YesNoUnsureOther
Section 4 - Pre-Departure & Contextual Cues
1. Does your dog appear anxious when you prepare to leave (e.g. pick up keys, put on coat)?*
2. How long after you leave do the signs begin?*
3. Typical duration of time left alone*
4. What is the longest comfortable time period your dog can currently manage?*
5. How does your dog behave when separated WITHIN the home (e.g. you in another room, behind a closed door)?*

RelaxedMildly unsettledDistressed (vocalising/scratching)Other
6. Is the dog ever left with another person or dog? Does this change their behaviour?*
7. Is your dog confined (ie. crate/room/free roam)? If confined, any signs of distress specific to the confinement?*
Section 5 - Behaviour When You Are Home
1. Does your dog shadow or follow you closely from room to room? *
2. Does your dog ignore food or sleep to follow you?*
3. Does your dog vocalise or scratch if you close the door between you?*
4 Where does your dog choose to rest when you are at home?*
5 Does your dog cope if another household member leaves while someone else stays*
Section 6 - Rule-Outs and Co-existing Issues
Does destruction or elimination ever occur when you are home? If yes, describe eg. possible house-training or boredom.*
Has your dog shown any fear of noises (e.g. thunder, fireworks)?*

YesNOOther
Any recent major household changes (move, new baby, schedule change)?*

YesNOOther
Any new medications, illness or pain noted recently?*

YesNOOther
Section 7 - Owner Observations
1. How does your dog behave when you return home?*

CalmOver-excitedAppeasement signals eg. rolls onto back, urinates etcAvoids eye contactOther
2. Have you used video or audio to observe your dog when left?*

YesNO
If yes, describe what you saw (behaviours, timing, recovery
3. What strategies have you tried so far? (e.g. enrichment, desensitisation, confinement, dog-sitter, medication)*
4. Did any of these approaches help or worsen the behaviour? *
4 Did any of these approaches help or worsen the behaviour*
5 What is your main goal or concern at this stage*
Section 8 - Severity & Impact

On a scale of 0–5 (where 0 = no problem and 5 = severe distress)*

Section 9 - Video / Recording Upload (optional)
If possible, please share a short (max 15 min) video of your dog alone from departure to first 10 minutes after. This helps identify precise triggers and recovery time.

Cancelof
Section 10 - Veterinary Information
Please confirm that your dog has had a recent veterinary examination to rule out medical contributors (pain, urinary, endocrine, neurological).*

Yes - within 3 monthsNo - Please book prior to behaviour plan
Section 11 - Consent
I confirm the information provided is accurate and consent to Talking Pet Behaviour processing my data (see Privacy Policy) and contacting my vet if necessary to support behavioural assessment.
Signature*

Clear
Date

DayMonthYear
Date
(CLINICIAN USE ONLY)
Scoring / Interpretation

Probable SRB = behaviours occur only when alone, consistently, and include ≥ 2 core signs (vocalisation, destruction, elimination, autonomic responses
Possible SRB + comorbidity = signs overlap with noise sensitivity, frustration, or confinement distress. Unlikely SRB = behaviour present when owner home, or absent during owner departure cues. (Algorithm cross-referenced from Overall et al., 2013; Lincoln Anxiety Scale; Malena DeMartini 2020 tool; van Rooy et al., 2018
Should be Empty:

Distress intensity (vocalising, destruction, pacing)

Frequency (how often SRB occurs)

Duration of distress

Impact on you as the owner (eg. noise complaints, property damage,stress)