Intake and Goal Assessment

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.

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? *

• Resource guarding
• Separation anxiety
• Extreme fear
• Aggression towards other dogs
• Aggression towards humans
• My dog has NOT shown any signs of these or similar behaviors.

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

• At particular things
• In particular situations
• In order to get something
• When he/she is restricted by a leash, fence, window, etc.
• Only when you are away
• As much when your home as not
• Only when you are home
• Barking is not an issue

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.

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