Dog Separation Anxiety Intake Form

Dog Separation Anxiety Intake Form

Share details about your dog, current alone-time challenges, and what you’re hoping to improve.
Guardian & Dog Basics
Guardian Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dog's Name
Dog's Age (Years)
Sex / Neuter Status
Breed / Mix, Acquisition Details, Time in Home, and Brief Prior History
Household Members and Other Animals
Presenting Problem & Goals
In your own words, what are your main concerns about your dog?
How long has this problem been going on?
How has the problem changed over time?
How distressing is this for your dog?

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10

1 is Mild, 10 is Severe
How distressing is this for you?

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1 is Mild, 10 is Severe
What would the ideal outcome look like? Please describe how long and how often you would like to be able to leave your dog alone.
Current Alone Time & Practical Constraints
How often is your dog left alone in a typical week?
About how long is the longest time your dog is alone at once?
Where is your dog usually left, and what confinement or setup is used?

Other
What monitoring or tech do you currently have available?

Other
Can you prevent distressing alone time during early training?
Separation-Related Signs When Alone

Signs when your dog is alone

Rows	Never	Sometimes	Often	Every time
Vocalizing (barking/whining/howling)
Pacing or restlessness
Panting
Focus on doors/exits
Destructive behavior
Self-injury
Elimination indoors
Drooling
Loss of appetite after being alone
Intense greetings when you return

Do these signs happen every time your dog is truly alone?
Have you had any neighbor or landlord complaints or reports about your dog when alone?
Clinginess & Behavior When You’re Home
Does your dog shadow or follow you around the home?
How does your dog respond to doors, baby gates, or other barriers separating you?
How well can your dog settle away from you when you are home?

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1 is Cannot settle at all, 10 is Settles very easily
Is your dog more upset when a specific person leaves, or when any human leaves?
Medical & Medication History
Veterinary Clinic Name
Date of Last Veterinary Exam

MonthDayYear
Date
Known Medical Issues
Recent Health or Behavior Changes
Current Medications, Supplements, Diet, and Veterinary/Behaviorist Involvement
Behavior Beyond Separation
General temperament description
Other behavior concerns

Other
Training & Management History for Separation Anxiety
What trainers, behavior professionals, or programs have you worked with for separation anxiety?
What has helped at least a little, and what has clearly made the problem worse?
Human Factors, Capacity, and Upcoming Changes
Which time commitments can you realistically maintain for a separation-anxiety program?

Other
Are any upcoming life changes likely to affect your training plan in the next 6 months?

Other
How is this problem affecting you emotionally, and what worries you most if it does not improve?
Risk, Safety, and Housing
When left alone, what risk behaviors have you seen?

Other
Describe any property damage or complaints related to being left alone
If the problem does not improve, what is the risk to your housing or placement?

Other
Referral Source, Permissions & Wrap-Up
How did you hear about us?
Referring person or organization
What do you love most about your dog?
Anything else you want us to know?
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Should be Empty:

Dog Separation Anxiety Intake Form

Guardian & Dog Basics

Presenting Problem & Goals

Current Alone Time & Practical Constraints

Separation-Related Signs When Alone

Clinginess & Behavior When You’re Home

Medical & Medication History

Behavior Beyond Separation

Training & Management History for Separation Anxiety

Human Factors, Capacity, and Upcoming Changes

Risk, Safety, and Housing

Referral Source, Permissions & Wrap-Up