Homevisit Form

STAR Home Visit Form
Date of Home Visit:

MonthDayYear
Potential Adopter Information:
Full Name:*

First NameLast Name
Street Address:*
City:*
State:*
Zipcode:*
Email*
Contact Number:

Area CodePhone Number
Animal Applied for:*
Neighborhood:
Describe the street:*

Urban - busy streetSuburban - some traffic during certain times of day, or busier streets near bySuburban - off major streets, little trafficRural
Describe the setting:*

UrbanSuburban - near urban areaSuburban - rural or semi rural areaLakeRural/farm area
Are there any potential hazards in the community?

YesNo
If there are potential hazards, please describe
What is the neighborhood like?
Fence/Yard:
Is the yard fenced?*

noyesyes partial
If yes, what type of fence?
If yes, is there anything near the fence that the animal could climb on to get over the fence?

Noyes
If yes, are there potential escape routes ? (i.e. low places near or under fence, holes etc.)

yesno
If yes, does the fence appear to need repair?

yesno
If no fence, is applicant planning on installing fencing?

yes- invisible/underground fencingyes- physical fencenoonly if needed
If considering invisible fencing, is the applicant aware that this does not work with all dogs?

yesno
Are there places in the yard the pet could jump off of and get injured? (i.e. decks, etc.)

yesno
Are there water features, lakes, or ponds in the yard or area?
Are there plants or chemicals visible in the yard that could be poisonous?

noyes
If any issues or hazards in the yard/area please list:
If yes, did you discuss with applicant?

yesno
If yes, are they willing to address?

Yes, they will address before adoptionNoother
If no or other please explain:
Home and Living Arrangements:
Type of Home*

Single Family w/yardSingle family no yardCondo/TownhouseApartmentFarm/Ranch
What is the overall condition of the home interior?*

Very nice - neat and tidyNice - generally cleanGood - cleanFair - some clutterBad - dirty with lots of clutter
What is the overall condition of the basement?*

No BasementMichigan BasementFinished - very neat and cleanFinished - generally clean, some clutterUnfinished - clean and organizedUnfinished - generally clean, some clutterDirty and cluttered
What is the overall condition of the garage?*

No GarageVery nice - clean and organizedNice - generally clean and organizedUsed mostly for storageVery cluttered and dirty
Do the furnishings of the house appear to be pet-proof? (no glass objects, dried flowers, potted plants at pet level, etc.)

yesno
Did you point out any hazards or items of concern being accessible to pet?

yesno
If you observed any issues or hazards in the yard/area did you point them out?
If yes, did they seem aware? or willing to address the issues?

Yes, are aware and will address before adoptionNo, not aware but willing to address before adoptionNo, concerned they will not address before adoptionOther
Pet Life
Where will the pet sleep?*

Crate in living space or bedroomCrate in separate roomCrated then free roamPet bed in living space or bedroomPet bed in separate roomOutside kennelFree Roaming in homeOther
Other (please explain):
Where will the pet stay during the day?*

CrateSeparate RoomFree RoamingOutside KennelCrate to start, then free roam
Where will the pet stay when the family is not at home?*

CrateSeparate roomFree roamingOutsideCrate to start, then free roamSectioned off area (baby gates)
Current Pets

(if applicable)
Are there current pets in the home?*

YesNo
If yes, what are the other pets?

DogsCatsSmall pets (hamster, ferret, guinea pig)Other
If there are other pets, do they seem clean and well-cared for?

yesno
If there are current dogs, do they seem well socicalized?

Noyes
If yes, do they approach you in a friendly manner?

YesNo
If the animal misbehaved, did applicant address it or ignore it?

addressed itignored it
What kind of discipline, if any, did you observe?

yellinghittingcalm correctionpositive renforcement
If you brought a "homevisit dog" with you, did their pets seem accepting of a new animal in the house?

yesnon/a
Family:
Were all family members present?*

yesnopart of the time
Are there children in the home?*

NoYes, small children under 10Yes, children over 10No, but expecting or will have children during the lifetime of the pet
If applicable, how did the children behave with pets?

kindgentleheavy-handedmean
Do all family members seem accepting of a new pet?

yesno
Training/Behavior:
How do they plan to exercise the pet? check all that apply*

walkstie outfenced yardjogging/runningDog park
Will the animal ever be left outside unsupervised?*

NoYesNot unless they are homeYes when they are home & gone sometimes
What type of behavior modification will they use?*

NonePositive ReinforcementClickerEnroll in obedience or training classesOther
If other, please explain:
Do they understand that it may take some time for the pet to adjust to the new environment?*

Yes, they are willing to give as much time as neededYesNo, they don't seem to be aware that it can take time
If no, did you explain that it can take time? if so, how did they respond?
Conclusions:
Do you feel the applicant will love and care for a pet properly?*

YesNo
Do you feel the environment is safe for a rescued animal?*

YesNoyes with changes, see below
Please list any changes or issues that need to be addressed before adoption:
If this were your animal, would you adopt him/her to this family?*

YesNo
Does this adoption feel right to you?*

YesNoI have reservations, see below
Please list any and all reservations you have -- please provide as much detail as possible:
Provide any additional thoughts or comments you feel the foster should know before adoption:
Volunteer's Name:*

First NameLast Name
Volunteer's E-mail Address:*
Should be Empty:

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STAR Home Visit Form

Potential Adopter Information:

Neighborhood:

Fence/Yard:

Home and Living Arrangements:

Pet Life

Current Pets

Family:

Training/Behavior:

Conclusions: