Homevisit Form

Date of Home Visit:

Month Day Year

Full Name: *

First Name Last Name

Street Address: *

City: *

State: *

Zipcode: *

Email *

Contact Number:

Area Code Phone Number

Animal Applied for: *

Describe the street: *

Urban - busy street Suburban - some traffic during certain times of day, or busier streets near by Suburban - off major streets, little traffic Rural

Describe the setting: *

Urban Suburban - near urban area Suburban - rural or semi rural area Lake Rural/farm area

Are there any potential hazards in the community?

Yes No

If there are potential hazards, please describe

What is the neighborhood like?

Is the yard fenced? *

no yes yes 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?

No yes

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

yes no

If yes, does the fence appear to need repair?

yes no

If no fence, is applicant planning on installing fencing?

yes- invisible/underground fencing yes- physical fence no only if needed

If considering invisible fencing, is the applicant aware that this does not work with all dogs?

yes no

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

yes no

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?

no yes

If any issues or hazards in the yard/area please list:

If yes, did you discuss with applicant?

yes no

If yes, are they willing to address?

Yes, they will address before adoption No other

If no or other please explain:

Type of Home *

Single Family w/yard Single family no yard Condo/Townhouse Apartment Farm/Ranch

What is the overall condition of the home interior? *

Very nice - neat and tidy Nice - generally clean Good - clean Fair - some clutter Bad - dirty with lots of clutter

What is the overall condition of the basement? *

No Basement Michigan Basement Finished - very neat and clean Finished - generally clean, some clutter Unfinished - clean and organized Unfinished - generally clean, some clutter Dirty and cluttered

What is the overall condition of the garage? *

No Garage Very nice - clean and organized Nice - generally clean and organized Used mostly for storage Very 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.)

yes no

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

yes no

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 adoption No, not aware but willing to address before adoption No, concerned they will not address before adoption Other

Where will the pet sleep? *

Crate in living space or bedroom Crate in separate room Crated then free roam Pet bed in living space or bedroom Pet bed in separate room Outside kennel Free Roaming in home Other

Other (please explain):

Where will the pet stay during the day? *

Crate Separate Room Free Roaming Outside Kennel Crate to start, then free roam

Where will the pet stay when the family is not at home? *

Crate Separate room Free roaming Outside Crate to start, then free roam Sectioned off area (baby gates)

Are there current pets in the home? *

Yes No

If yes, what are the other pets?

Dogs Cats Small pets (hamster, ferret, guinea pig) Other

If there are other pets, do they seem clean and well-cared for?

yes no

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

No yes

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

Yes No

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

addressed it ignored it

What kind of discipline, if any, did you observe?

yelling hitting calm correction positive renforcement

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

yes no n/a

Were all family members present? *

yes no part of the time

Are there children in the home? *

No Yes, small children under 10 Yes, children over 10 No, but expecting or will have children during the lifetime of the pet

If applicable, how did the children behave with pets?

kind gentle heavy-handed mean

Do all family members seem accepting of a new pet?

yes no

How do they plan to exercise the pet? check all that apply *

walks tie out fenced yard jogging/running Dog park

Will the animal ever be left outside unsupervised? *

No Yes Not unless they are home Yes when they are home & gone sometimes

What type of behavior modification will they use? *

None Positive Reinforcement Clicker Enroll in obedience or training classes Other

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 needed Yes No, 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?

Do you feel the applicant will love and care for a pet properly? *

Yes No

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

Yes No yes 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? *

Yes No

Does this adoption feel right to you? *

Yes No I 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 Name Last Name

Volunteer's E-mail Address: *

STAR Home Visit Form

Potential Adopter Information:

Neighborhood:

Fence/Yard:

Home and Living Arrangements:

Pet Life

Current Pets

Family:

Training/Behavior:

Conclusions: