Intake Weebly

Assessment Form

Please provide as much detail per question as you can. The more in depth, the better. Only questions with a red asterisk are required.

* Indicates required field

Your Name *

First

Last

Spouse/Partner's Name *

First

Last

Address (please include apartment/bell/floor/suite) *

Line 1

Line 2

City

State

Zip Code

Country

Your Cellphone Number *

Spouse/Partner's Cellphone Number *

Home Phone Number *

Your Email *

Spouse/Partner's Email *

Your Occupation *

Spouse/Partner's Occupation *

How did you hear about us (so we can thank them)? *

When is everyone in your home generally free? *

Weekday afternoons (1 PM - 4 PM) Weekday evenings (4 PM - 7 PM) Saturday mornings (9 AM - 12 PM) Saturday afternoons (12 PM - 4 PM) Saturday evenings (4 PM - 7 PM)

Your Dog's Name *

Your Dog's Breed (or best guess) *

Your Dog's Age (or best guess) *

Your Dog's Weight (or best guess) *

Your Dog's Sex *

Intact Female Spayed Female Intact Male Neutered Male

If your dog is altered (spayed or neutered), at what age was the surgery done? If not, and you are planning on altering your dog, when is the expected age or date of surgery? If you are not planning on altering your dog, why not? *

If your dog is altered, did you notice any physical or behavior changes after the surgery? *

Photo of Your Dog *

Max file size: 20MB

Where did you get your dog? *

How did you find out about this place/person? *

When did you get your dog? *

Is this the first dog you have been primarily responsible for? If not, please tell me a little about any other dogs you have had before. If you have lived with other dogs before, but were not primarily responsible for them, please tell me about that as well. *

Why did you choose this particular dog (ex. the way she looks, coloring, behavior, quietest, most rambunctious, most playful, got along best with your children/current dog, felt bad for her, etc.)? *

What role did you imagine this dog would play in your home? *

What activities did you plan to do with your dog? *

Have you ever met your dog's parents? If so, please describe their personalities and behavior. If you saw the location your dog lived in at the time, please describe that as well. *

How many littermates did your dog have? *

How old was your dog when you adopted/bought/rescued her? *

If your dog has had any previous homes that you know about, please list them here (and reasons for leaving that home, if known). *

Veterinary Clinic Name *

Veterinarian Name *

Veterinarian Phone Number *

Veterinarian Address *

Line 1

Line 2

City

State

Zip Code

Country

When was your dog's last vet visit? *

Reason for visit? *

How does your dog usually behave at the veterinarian's office? *

What is your dog's medical history? Has your dog had any surgeries, illnesses, hospitalizations, etc.? *

What medication and/or supplements is your dog currently taking? Please include prescription medications as well as nutritional supplements. *

Doe your dog have any sensitive areas on her body, or places she doesn't like to be touched? If so, what is her reaction if she's touched there? *

Please list the names of every person currently sharing the home with your dog. If there are children under 18, please list their ages. Please also include a short description of their relationship with your dog. *

Does your dog show favoritism toward any person(s) in the home? If so, please describe who, and the associated behavior. *

Please list the name, species, breed, sex, whether or not they're altered, and age of all other animals sharing the home with your dog. Please also include a short description of their relationship with your dog. *

Have there been any recent changes to your dog's home or immediate environment recently (ex. death of a family member or other pet, recent move, recently added family member or pet, recent illness, recent stress between human household members, etc.)? *

Does your dog have any allergies or sensitivities (environmental or food based)? *

What brand of food are you feeding your dog? Kibble or canned? What meat types (beef, chicken, lamb, pork, fish, etc.)? *

Is your dog a picky eater, or does she love her food? Please describe her eating habits. *

How much food does your dog get per meal? How many meals per day? Where do you feed your dog? *

Where does your dog spend time when no one is home? *

How long, on average, does your dog spend home alone every day? *

Where does your dog sleep at night? *

Have you noticed any changes in your dog's sleeping habits recently? If so, please describe them. *

Is your dog crate trained? *

Yes No Mostly, but still cries sometimes.

Is your dog potty trained? *

Yes, only goes outside Yes, only goes on Wee Wee Pads/paper/etc. inside Yes, only goes outside and on Wee Wee Pads/paper/etc. inside Sort of, mostly goes outside, but still has accidents in the house Sort of, mostly goes on Wee Wee Pads, but misses/has accidents frequently No, goes all over the place

Does your dog ever pee from excitement, fear, or when meeting people or dogs? If so, please describe the behavior and what causes it. *

Please describe what an average day of walks looks like. Please write it in the following format: time, who does the walk, how long the walk is, where the walk is. (Ex. 8:00 AM, Joe, 15 min, around the block.) *

What other regular exercise does your dog get? How many minutes a day would you say your dog gets to run? *

What, if any, previous training has your dog had? If you worked with a trainer or training school, what was his or her name? How would you describe the methods of the training? What tools did they use? *

What do you do when your dog misbehaves? (Ex. yell "no", jerk the leash, use a spray bottle, rattle a penny can, clap your hands, smack/tap your dog's butt, grab your dog's face/muzzle, roll your dog on his side, put your dog in his crate, leave the room, etc.) *

Does your dog dislike certain people or dogs? *

Yes No

If so, who or what don't they like? *

How does your dog generally react when a stranger enters the home? What is your "greeting" routine to introduce new people? *

Does your dog have any fears, phobias, or sensitivities (ex., loud sudden noises, trucks passing, thunderstorms, plastic bags outside, shadows, etc.)? *

Has your dog ever growled at you or other members of the family? *

Yes No

Has your dog ever snapped at or bitten you or other members of the family? *

Yes No

Has your dog ever growled at a stranger? *

Yes No

Has your dog ever snapped at or bitten a stranger? *

Yes No

If you answered "yes" to any of the last four questions, please describe each incident in which your dog growled/snapped at/bit someone. Include what happened just before (what the dog and human were doing), what your dog did, and what happened right after (what did you or the human do, what the dog's reaction was). *

Has your dog ever bitten another dog? *

Yes No

Has your dog ever been bitten by another dog? *

Yes No

Has your dog ever bitten or killed another animal (cat, squirrel, mouse, rat, bird, etc.)? *

Bitten Bitten and killed No

If you answered "yes" to any of the last three questions, please describe each incident with as much detail as possible. Please include what the animals were doing just before the bite, how the biting occurred, what happened just after (any human reactions including your own, and how the dog responded). *

If you answered "yes" to any bite or snapped at question, please check the box next to any level that your dog has done, you can check multiple boxes if they apply (based on the Dunbar bite levels). *

Level 1. Obnoxious or aggressive behavior but no skin-contact by teeth. Dog growls, lunges, snarls. Level 2. Skin-contact by teeth but no skin-puncture. However, may be skin nicks (less than one tenth of an inch deep) and slight bleeding caused by forward or lateral movement of teeth against skin, but no vertical punctures. Level 3. One to four punctures from a single bite with no puncture deeper than half the length of the dog’s canine teeth. May be lacerations in a single direction, caused by victim pulling hand away, owner pulling dog away, or gravity (little dog jumps, bites and drops to floor). Level 4. One to four punctures from a single bite with at least one puncture deeper than half the length of the dog’s canine teeth. Typically contact/punctures from more than canines only. Black bruising, tears and/or slashing wounds. Dog clamped down and shook or slashed victim. Level 5. Multiple-bite incident with at least two Level 4 bites or multiple-attack incident with at least one Level 4 bite in each. A concerted, repeated attack. Level 6. Missing flesh, flesh consumed, victim dead.

Does your dog ever guard food, toys, treats, other objects, locations, or people from you or anyone else? *

Yes No

If yes, please describe what your dog guards, against whom, what you currently do in that situation, and your dog's reaction. *

How would you describe your dog's personality? *

What are your dog's favorite treats? Will she eat them outside, with distractions around? *

What are your dog's favorite activities, toys, or games? If it were your dog's choice, what would she get to do all day long? *

What behaviors would you like me to help you work on? Please list them in order of priority, and put a star (*) before the most urgent ones. Please also give a description of any known triggers for the behavior, and how often it occurs. *

How are you currently dealing with/working on these behavior issues? What have you tried, for each one, to make it better? What is your dog's reaction to that, usually? *

Please list what your goals are for the above behavior issues. Please include one short term goal, and one long term "ideal" goal. *

Would you like to apply any discounts from the Incentives page? *

Exchange your choke/prong/spray/shock collar for a front clip harness (limit one harness per dog). $35 off any one training service for dogs who were adopted within the last 3 months (with proof of adoption). 40% off any service for dogs currently in foster care (with proof of ownership by rescue organization). $50 off any one dog training session for the family that adopts a dog in foster care that I have been working with.

Submit

Assessment Form

Please provide as much detail per question as you can. The more in depth, the better. Only questions with a red asterisk are required.

Thank you for filling that out! I know it was long, so please enjoy a clip of pups having a good time!