Intake and Goal Assessment

Your Name

First

Last

Your Email

Your Phone Number

Your Dog's Name

Your Dog's Age

Your Dog's Breed

If your dog is a mixed breed, please indicate which breeds, to the best of you ability

Your Dog's Gender

Male, not neutered
Female, not spayed
Male, neutered
Female, spayed

When did you acquire your dog? Where did you get your dog from? (Shelter, rescue, breeder?)

When was your dog's last vet visit?

What procedures were performed?

Describe your dog's daily routine/schedule

What does your dog do for exercise? How often and for how long?

What does your dog do when you are away from the house? (Crated, in a pen, free range of the house, etc.)

What kinds of toys, chew, etc does your dog play with, and how often? When does he/she play with his/her toys?

Have you done any training with your dog, or did your dog receive any training prior to you acquiring him/her?

If yes, please indicate where the training took place and what approach to training was taken (particular training methods, equipment), and if that training yielded results.

What are your dog's favorite foods or treats? Does your dog find toys to be more fun than food during training?

Has your dog experienced or demonstrated any of the following?

Please select all that apply

If you checked any of the boxes above, please explain in as much detail as possible.

Does your dog bark?

Yes
No

Does your dog seem to bark excessively

Please select all that apply

Please elaborate on any of the boxes checked above

Does your dog soil indoors?

Yes
No

If you answer yes, please elaborate in the next few questions

When did this begin?

How often does your dog soil indoors?

When does your dog tend to soil indoors? Is there a particular time or event associated with it?

Does your dog:

Chew or scratch to the point of hair loss or bleeding
Display anxiety when you are leaving
Refuse food when you are away
Greet excessively when you return
Chew on doors or windows
Escape regularly while you are away
My dog shows NO signs of separation anxiety

If you check any boxes, please elaborate for EACH in the next question

Please elaborate any checked boxes from previous question

Include as much detail as possible on specific events, times, circumstances, behavior observed, etc

What is your dog doing that you would like to stop? What would you like him/her to do instead?

Please include when and where your dog does this.

What would you like your dog to do?

Please be specific and list as many things as you would like. Examples would be walking nicely on a leash, earning a title, learning a specific behavior, etc.

What would you like to be able to do with your dog?

This may include things such as competitive sports, therapy work, specific testing, etc.

This form helps me understand where you and your dog are, and where you want to be. You will receive a copy of your answers. Please retain them for your records. If you have any issues, please contact us.