Intake Questionnaire

Thank you for contacting me to help you with your dog’s behavior.  Please complete the questionnaire below and press Submit.  I would love it if you could fill it out at least 48 hours before your appointment, so I can be well-prepared.

 

Of course, I will keep all your information confidential.  Occasionally, third parties may request access to confidential information (such as your veterinarian).  If this happens, I will ask for your permission before releasing any information. 

 

Behavior programs can be demanding and require a high level of commitment from all family members.  Your goals are very important to creating the program, and your motivation is the key ingredient to success.  I’ll do my best to support your process of meeting your goals and will be in touch with you in-between sessions via email  to address your issues and concerns and coach you over the rough spots.  Feel free to call, text, or email me for support whenever needed.

 

Your appointment time is reserved especially for you. If you’re unable to keep your appointment, please let me know as soon as possible so I can make it available to someone else.  I look forward to meeting you!

 

Your Information

Owner Name

Full Address (please include city, state and zip)

Phone Number

Email Address

How did you find out about Wise Dogs?

Dog’s Name

Dog's Breed

Dog's Age/Birthday

Are they spayed/neutered?

If yes, how old were they when they had the surgery

Vet Clinic

Veterinarian your dog sees

Clinic Address

Clinic Phone Number

Please answer these Yes or No Questions. Saying “no” will not disqualify you for receiving help.

May we contact your veterinarian if necessary?    

Do you authorize your veterinarian to release information about your pet?

May I send a courtesy letter to your veterinarian, advising them that you asked for my help?

May we video tape your session or parts of it? 

May I post photos & videos of your pet on Facebook?

Your Pet’s History, Behavior and Lifestyle

History

Where did you get your pet and how old were they when you acquired them?

Why did choose your dog?

What do you know about your dog’s history?

Training History

Have you taken your dog to any training classes? If so, please describe the type(s) of class(es) you have taken with your dog.

Have you worked with a trainer before? Please describe what you worked on in the past with a trainer.

Have you tried any training online or read any books on dog training? If so, what has been the most helpful for you and your dog.

What cues/commands does your dog know? Please note what they do the BEST.

Diet

What kind of food does your dog eat for their daily diet?

What are your dog’s favorite foods/treats?

Do you give your dog any supplements? If so, please describe

Behaviors of Concern

Describe the behaviors you need help with. Fill out as many as apply.

 Please include:

When the behavior started?

Where it occurs?

How often it occurs?

What you have tried to resolve the behavior

How effective was your intervention

Bite Hitstory

If your pet has a history of aggression or biting, please describe it in the form below.  Start with the earliest known incident, end with the latest known. For each incident answer the following questions. Fill out as many as apply.

Be very specific

1. Date of incident
2. Who (person or another animal) did the dog threaten or bite?
3. What was going on at the time of the threat or bite?
4. Where did the threatening behavior or bite happen?
5. What part of the victim’s body was bitten?
6. Level of Bite

Bite Level 0: Threat, including staring, growling, snarling, baring teeth, barking, or any other behaviors that make you uncomfortable.

Bite Level 1: Snap and miss.

Bite Level 2: Contact: leaves bruise or red mark.

Bite Level 3: Single puncture.

Bite Level 4: Multiple punctures.

Bite Level 5: Mutilation.

Bite Level 6: Death.

Physical & Mental Stimulation

What kind of exercise do you do with your dog and how often do you do each activity?

What kind of games/playtime do you have with your dog? How often do you do each activity?

What are your dog’s favorite toys?

Do you use a crate with your dog? If so, how often do you use your crate? How does your dog behave in their crate?

Household

How many other pets do you have? Please list the species, name, and approximate ages.

Please list the people living in the home besides yourself, their names and their relationship to you (example: spouse, roommate, child, etc.). The ages of the children are especially important for aggression cases.

Medical History

Is your dog up to date on rabies? When does your dog’s rabies vaccination expire?

When was your dog’s last physical exam?

Does your dog have any health problems or have they had any major surgeries?

Is your dog currently on any medications?