Behavior United Intake Form

Behavior Intake Form
The insight and knowledge you share about your pet through this quick form allows us to customize a plan before sharing solutions. Submitting this form brings you one step closer to gaining more quality pet time! After this form has been submitted and reviewed, scheduling can begin.
Your Information
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*

Area CodePhone Number
Names of people in the home:*
For children under 18yo, please include ages.
Would you like to receive periodic email updates about upcoming events, classes, and promotions?*

YesNo
How did you hear about us?*
Pet Information
Pet(s) to be seen in session*
Other Pet(s) in home
Please list any other pets in the household and their species, breed, and age
Is your pet house and/or crate-trained?*
For how long and where is your pet left alone each day? (If Separation Anxiety, how long can your dog be alone?)*
Describe your pet's sleeping habits in terms of how long they sleep and the quality of their sleep. (For example: Are they restless? Do they stay settled once asleep? Do they startle easily?)*
Pet exercise type/frequency plus mental enrichment like chews and food puzzles*
Equipment used on walks*
Type of collar/harness/leash
Medical History
Veterinarian Name/Practice*
Please list any previous or current medical issues your pet has had:*
(Please include any dietary restrictions)
Have you ever suspected your pet(s) may have physical (ex: gastrointestinal, musculoskeletal, or skin) discomfort? Please describe. *
Please List Vaccinations and Dates for Rabies/DHLPP:*
Have you spoken to your vet about your dog's behavior challenges? List any/all behavior and pain medications. *
Training and Behavior History
Please list any known previous training/methods used:*
What do you use to reward your pet? What is your pet's response?*
What type of correction/punishment do you use with your pet? What is your pet's response?*
What are your training goals/reasons for contacting us? *
Which training package are you interested in?*
Which version of the training package are you interested in? (Separation Anxiety is All Online)*
Has your pet ever bitten another animal or person? Please describe below and include a description of bite location and severity plus if medical attention was required*
Is your pet possessive or protective of anything? Please describe below:*
Is there anything you would like to add about yourself or your pet(s)?
Should be Empty:

Behavior Intake Form

Your Information

Pet Information

Medical History

Training and Behavior History