Prospective Separation Anxiety Client Questionnaire
Let me learn a little more about you and your dog.
If your dog is suffering from a separation related issue and you would like us to consider working with you, please take a moment to fill out the following questionnaire. Once this form is submitted I will be in touch to set up an assessment. The assessment is a remote consultation approximately 60-minutes long and will cost $150.00 plus tax.
Name
*
First Name
Last Name
Email
*
Confirmation Email
example@example.com
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Location ( City, State/Province, Country )
*
Dog's Name
*
Age of Dog
*
Gender of Dog
*
Male
Female
Where was your dog acquired?
*
Breeder
Shelter/Rescue
Other
Breed or Mix Type
*
How long has your dog been in your household?
*
Less than 6 months
6-12 months
1 -3 years
Greater than 3 years
How long is your dog currently being left alone?
*
None
Less than 1 hour
1-2 hours
2-4 hours
4-6 hours
6-8 hours
More than 8 hours
If you have any additional comments regarding your dog's current alone time, please describe here.
0/200
Can you adjust your schedule so that your dog will not be left alone except while training for a while?
*
Yes
No
Maybe
Please keep in mind that your dog is not considered to be alone when accompanied by someone, in or outside your home or they are in an environment where they are comfortable eg day care.
Have you done any previous training to address your dog's separation anxiety?
*
Yes
No
If you answered 'Yes' to the above question, please explain.
0/200
Have your discussed your dog's separation anxiety with your Veterinarian?
*
Yes
No
If you answered 'Yes' to the above question, please explain.
0/200
How long would you like to be able to leave your dog alone in the future?
*
Less than one hour
1-2 hours
2-4 hours
4-6 hours
6-8 hours
More than 8 hours
If you have any additional comments regarding your dog's future time alone, please describe here.
0/200
If you have any other information that would be relevant for me to know, please provide here.
0/200
Please let us know how you heard about us.
Referral (Friend/Colleague/ Relative)
Online Search
Facebook
Trainer
Other
If someone referred you to us, please provide their name here.
Enter the message as it's shown
*
Submit
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