Behavior History

Behavior History 2023

Please complete each field with as much detail as possible. Even if the question is not required, PLEASE GIVE ME ALL OF THE INFORMATION. Read the questions carefully.
How many family members in your home (including you)?*
Please tell me about each Family Members (including yourself)*
Who is the Primary Contact?*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number 1*
Phone Number 2
What is your availability (check all that apply)?*

Weekday morningsEveningsWeekends
Main Pet Information*
How many other pets do you have?*
Tell me about your other pets
Veterinarian Information*
Previous Trainer Information*
Petsitter / Dog Walker Information
Daycare Information
Groomer Information
Please give a general description of the main problem behavior (I will ask for specific examples later). *
Please include your dog's body posture or movements before, during and after this behavior
When did you first notice the problem?*
How frequent are the incidents; how many times has it happened?*
Are there any conditions which seem to trigger this behavior?*
Please list known triggers
What is the average duration of this behavior?*
Do the incidents vary in intensity?*
Does the behavior seem to intensify at certain times of the day or during certain activities*
Please give as much detail as possible
Can the dog be distracted and redirected during this behavior? If yes, please describe how.*
Please list any techniques you have used to distract or redirect your dog,.
What have you done to try to correct this problem? How did the dog respond? *
Please list different tactics separately and include how the dog responded.

Additional Behavior Information
Please describe any other incidents of the main unwanted behavior.*
Please list the same details as the previous pages.
Are there any secondary problems? Please give as much detail as possible.*
(Jumping, Growling, Mounting, Chasing, Destructive Chewing, etc)
Does your dog have any quirky habits?*
(Paw-licking, face-licking, obsessive ball hoarding, repetitive rituals, etc)

Enrichment & Sociability
What kinds of dog toys does s/he have, and how many?*
What kind of exercise does the dog get?*
What kind of games are played with the dog?*
Outdoor Environment*
How does s/he act? What does s/he do outside?*
(digging, barking, running the fence, hiding, sunbathing, etc)
Where is the dog during the day?*
Where is the dog when left home alone?*
How long is the dog left home alone each day?*
Where is the dog when you have guests?*
Where does the dog sleep at night?*
How does s/he act with familiar visitors?*
How does s/he act with UNfamiliar visitors?*
How does s/he react to other dogs both on and off leash?*
How does s/he react to Fast-moving objects like cars, bicycles, birds, etc?*
How does s/he react to loud noises like thunder, fireworks, etc?*
How does s/he react to family departures & homecomings?*
Does your dog seem anxious when you are getting ready to leave home?*
(restlessness, pacing, salivation, shadowing you, etc)
Is there a prolonged "relief" type greeting when you return home? *
(most dogs are excited, but if it lasts more than a minute or two it could be a sign of separation distress)
Has there been any evidence of excessive vocalizing or destructiveness when alone?*
(video is valuable if this is the case)
Does s/he respond to directions equally from all family members?*
Describe the family activity level in the home.*
Have there been any recent changes to your household?*
Additions or departures of people or pets, or a move - Please explain in detail
Neurological information*
Has your dog had any issues with coordination or lameness that you have noticed?*
Please describe in detail
How often is your dog bathed or groomed, and how does s/he tolerate it?*
Please describe in detail

Training History
What type or style of collar or harness do you use when walking? *
Please indicate if you have tried different collars/harnesses
Please describe your dog's prior training? PLEASE BE SPECIFIC on HOW you taught any behaviors.*
Where, what tools or devices were used, what did you learn?
Tell me about any dogs you have had prior to this one.*
Please describe YOUR prior experience working with a trainer or behavior consultant? PLEASE BE SPECIFIC*
Where, what tools or devices were used, what did you learn?
How did you hear about The Refined Canine?*
What do you hope to accomplish by working with me? *
What if it doesn't happen, what will you do with the dog? *
What are some of your dog's BEST qualities? *
Did anything surprise you, or did you learn anything new while completing this form? *
What else would you like me to know that might help us improve this problem?*
What questions do you have for me?

Terms & Conditions

These terms take effect IF and WHEN we actually decide to work together, either virtually or in person.
Liability Waiver & Acknowledgement
- I acknowledge that all fees are non-refundable.
- I understand these services must be used within six months. If I must cancel a lesson or miss a class, I will notify my instructor in advance of the scheduled lesson or class time. Private lessons will be rescheduled if I have given 24-hours notice. Make-up classes will be offered, when available, if I have given 24-hours notice. Exceptions for emergency situations may be considered on an individual basis, but are not guaranteed. I understand and accept that it is my responsibility to schedule lessons in a timely manner and that after six months with no contact from me, my contract will expire and all remaining lessons or classes will be forfeited.
- I understand that The Refined Canine, LLC and all agents and partners thereof make no guarantees regarding the success of training endeavors, or the rehabilitation or modification of behavior problems. The Refined Canine, LLC, and all agents and partners thereof assume no responsibility for the behavior of any dog(s) currently enrolled in any training or behavior modification program.
- I accept full responsibility for the behavior of my own dog at all times.
- I understand that all materials produced, published, distributed, or shared during the course of training or behavior counseling are copyrighted materials and are shared with permission, and they are not to be reproduced or distributed without the express permission of the original authors.
- I agree not to reproduce or distribute any materials, print or electronic, that have been published by Michelle Douglas or The Refined Canine LLC, except those which are listed publicly online.
Media Release & Authorization

I agree to allow The Refined Canine, LLC and my instructors to take video and photographs during consultations, classes, or lessons, and to use any media which may contain myself, my dog, or my family for educational or marketing purposes, including but not limited to seminar presentations, online publishing and printed materials. I hereby release The Refined Canine, LLC, and its employees or agents from any and all claims for damages based on such materials. I release all claims of copyright ownership of such materials to Michelle Douglas and The Refined Canine, LLC. I agree to allow Michelle Douglas and The Refined Canine, LLC to use information about my dog and our case for educational purposes. I understand that my personal information will remain confidential.
COVID-19 & Viral Illnesses Standard Business Waiver
- I acknowledge the contagious nature of the coronavirus/COVID-19, Influenza, and other viral illnesses, and that many public health authorities recommend practicing social distancing.
- I further acknowledge that The Refined Canine LLC can not guarantee that I will not become infected with the coronavirus/COVID-19, Influenza, or any other viral illnesses. I understand that the risk of becoming exposed to and/or infected by the coronavirus/COVID-19, Influenza, and other viral illnesses may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, and other clients and their families.
- I voluntarily seek services provided by The Refined Canine LLC and acknowledge that I am increasing my risk of exposure to the Coronavirus/COVID-19, Influenza, and other viral illnesses.
- I hereby release and agree to hold The Refined Canine LLC harmless from and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses, and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of The Refined Canine LLC, or that may otherwise arise in any way in connection with any services received from The Refined Canine LLC. I understand that this release discharges The Refined Canine LLC from any liability or claim that I, my heirs, or any personal representatives may have with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from The Refined Canine LLC.
- This liability waiver and release extends to The Refined Canine LLC together with all owners, agents, partners, and employees.
Fee Disclosures 2023 - No Fees are due unless and until we schedule a consultation.

Behavior Consultation ~ $250 and up
- This is a 2-hour appointment, plus the follow-up email with an outline of the plan we discuss, as well as any written materials, and links to videos and other resources.
- $250 ~ Zoom Consult
- $450 ~ In-Person Consult (generally not recommended for the initial consultation)
- $600 ~ Zoom Consult plus three 1-hour follow-up sessions (pre-paid)
- $800 ~ Zoom Consult plus five 1-hour follow-up sessions (pre-paid)
- $1250 ~ Zoom Consult plus ten 1-hour follow-up sessions (pre-paid)
Written Behavior Plan ~ $200
- A detailed, written plan which is specific to your dog is priced separately. The consultation will give you an outline with links and additional materials, but if you would like a detailed plan (usually around 15 pages), this is an additional charge and will take about a week after our consultation.
Add-on Follow-up Sessions
- $75 ~ 1/2 hour (Zoom only)
- $150 ~ Single 1-hour session (Zoom or in-person)
- $400 ~ Three 1-hour sessions (Zoom or in-person)
- $650 ~ Five 1-hour sessions (Zoom or in-person)
Additional Fees
- $50 ~ for every 15 minutes of travel time beyond a 1-hour round-trip
- $50 ~ for every 30 minutes we go over an hour (2 hours for consult)
- $75 ~ one-time fee for additional pets (up to 3)
- $400 ~ Refining Reactivity Class if approved and available
Additional fees may apply and will always be discussed in advance.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Type your name as signature*
Please type your name as signature
Signature
Should be Empty:

	No Reaction	Turn Away	Run Away	Snarl	Lift Lip	Bark	Growl	Snap	Bite	N?A
Take dog's dish with food
Take dog's empty food dish
Take dog's water dish
Take food that falls on the floor
Take rawhide or chew
Take real bone
Take biscuit
Take toy
Human approaches while eating
Dog approaches while eating
Human approaches while playing w/toy
Dog approaches while playing w/toy
Human approaches while sleeping
Dog approaches while sleeing
Step over dog
Push dog off bed/couch
Reach toward dog
Reach over head
Put on leash
Push on shoulders
Push on rump
Towel feet when wet
Bathe dog
Groom dog's head
Groom dog's body
Stare at
Take muzzle in hands and shake
Push dog over onto back
Stranger knocks at door
Stranger enters room
Dog in car at drive thru
Dog in parked car
Dog on leash approached by dog on street
Dog on leash approached by person
Dog in yard, person passes
Dog in yard, dog passes
Dog in vet's office
Dog in boarding kennel
Dog at groomer
Dog yelled at
Dog corrected with leash
Dog physically smacked
Someone raises voice to owner
Someone hugs owner
Small animals
Bicycles/skateboards
Crying infant
Playing with toddler
Playing with 5-7 yr children
Playing with older children

Behavior History 2023

Please Describe the Most RECENT Incident

Please describe another example of unwanted behavior.

Additional Behavior Information

Daily Life Questions

Enrichment & Sociability

Training History

Aggression Screen

Terms & Conditions