Holistic Spirit Dog Intake & Program Enrollment

1
Dog Owner Name(s)* This field is required.
2
Phone Number* This field is required.
Please enter a valid phone number.
3
Email* This field is required.
example@example.com
4
Full Residence Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Mailing Address (If Different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Please list any other humans who live with you or who visit frequently (include names, ages, relationship):* This field is required.Type "none" if you live with no other humans
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7
Primary Dog's Name* This field is required.
8
Primary Dog's Breed* This field is required.
9
Primary Dog's Age* This field is required.
10
Primary Dog's Sex* This field is required.
Intact male
Intact female
Neutered male
Spayed female
11
Primary Dog's Weight* This field is required.
12
When did you get your dog, from whom, and how old was your dog at that time?* This field is required.
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13
Please describe additional dogs in the household (names, ages, breeds, general behavior):
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14
Please describe any other pets in the household:
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15
How would you describe your dog in one sentence?* This field is required.
16
Please check all problem behaviors that apply to your dog.* This field is required.
Aggression to household members
Aggression to other people
Aggression to other dogs or other animals
Barks or whines a lot
Guards objects, food, etc.
Startles / afraid of certain things / anxious
Won't easily allow grooming / vet care (by you or others)
Separation anxiety or distress
Poor recall (won't come when called)
Barks, lunges, or growls during walks
Chases (animals, cars, joggers...)
Mouthing/nipping
House soiling
Difficult in the car / gets carsick
Destructiveness (objects, furniture)
Other
17
Describe how your dog reacts to strangers coming to your home, and what you usually do in those situations:* This field is required.
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18
Has this dog ever bitten or tried to bite a person?* This field is required.
Yes
No
19
If your dog has bitten someone, describe the circumstances, severity, frequency, and other relevant details:If multiple bites, describe the most recent or most severe incidents. Skip if no bite history.
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20
Has this dog ever bitten another dog? If yes, please describe the situation(s), severity, etc. * This field is required.
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21
Please describe any bite history for other dogs in your household (if applicable).
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22
Describe your dog’s main behavioral concerns in detail:* This field is required.Include what your dog does, who or what is involved, frequency of these behaviors occurring, your reactions, etc.
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23
What can you tell us about when these issues first appeared? * This field is required.E.g., "went back to work full time", "was attacked by another dog on a walk", etc.
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Are there any triggers or situations where the main concerning behavior(s) is more likely to occur?* This field is required.
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25
Have the main behavior issues...* This field is required.
Improved
Stayed the same
Gotten somewhat worse
Gotten much worse
26
What have you tried so far to manage or modify this behavior? Please be specific.* This field is required.
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27
Have you ever employed another trainer for this dog? If yes, please explain what you learned, methods used, results, etc.* This field is required.
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28
Interested in a Holistic Consultation? * This field is required.Our unique holistic consultation can support behavior modification and your dog’s overall wellbeing, including guidance on stress reduction, nutrition, supplements, herbs, and environmental enrichment. Would you like to hear more about this service?
Yes, please
Not at this time
29
Your Top Three Goals* This field is required.Please list the top three outcomes you hope to achieve
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30
Additional Goals* This field is required.Are there other specific goals or improvements you would like for your dog? Examples: easier visits to the vet, responding reliably to recall, improved confidence in new environments, etc.
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31
Current Skills* This field is required.Please list the cues, commands, or tricks your dog already knows.
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32
Optional Notes Use this space to share any other thoughts about your training goals or priorities that may help us plan the program.
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33
Please describe your dog's daily routine:* This field is required.Include sleep/naps, meals, time spent home alone, walks/exercise sessions, training sessions, etc.
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34
What type(s) of exercise does your dog get, when and how much?* This field is required.
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35
What are your dog's favorite activities or games?* This field is required.
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36
What does your dog dread most?* This field is required.
37
Primary Veterinarian Name
38
Vet Clinic Name
39
Clinic Phone Number
Please enter a valid phone number.
40
Vet/Clinic's Email
example@example.com
41
Emergency Contact (if different)
42
Behavior Service Contract - PLEASE READ FULLY* This field is required.
43
Please sign below to confirm that you have fully read and agree to the terms of the Behavior Services Contract.* This field is required.
Powered by Jotform SignClear
44
Has your dog ever bitten any human or animal, whether or not an injury occurred?* This field is required.
YESNO
45
By initialing below, I acknowledge that I have accurately disclosed any known bite history for this dog (if applicable) and understand the associated safety responsibilities.* This field is required.
46
Date of Agreement* This field is required.
Date
Month
Day
Year
47
May we use photos or videos of your dog, and of you or your family (including children, if any), on our website or social media?
Yes
Yes, but without showing human faces
No
48
Would you like to receive occasional training tips, holistic insights, and other updates via email?Would you like to receive occasional training tips and updates via email?
Yes, please
No, thank you
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