Intake Assessment Form

ABOUT YOU FULL NAME ADDRESS CITY, STATE, COUNTRY, ZIP CODE PHONE NUMBER EMAIL ADDRESS: How long have you been training dogs (as an owner, trainer or competitor)? Why are you enrolling your dog in the Control Unleashed course? ABOUT YOUR DOG DOG'S NAME DOG'S BREED (OR BREEDS) DOG'S AGE DOG'S SEX/STATUS MALE NEUTERED MALE INTACT FEMALE SPAYED FEMALE INTACT DOG'S APPROXIMATE HEIGHT/WEIGHT How long have you had the dog? Where did you get your dog? Breeder Rescue/Shelter Rehome Bred by you How old was your dog when it joined your household? TRAINING Please list classes you are currently attending or have recently attended with your dog: Are you currently performing or competing with your dog? If yes, please describe: My dog is trained in the following behaviors: Eye Contact Targeting (hand/object) Go to Mat/Place Doggie Zen/Leave It Rest in Crate Are there any circumstances in which your dog is unable to perform any of these behaviors? Please describe: RESPONSE HISTORY My dog gets "sniffy" (choose all that apply): in class at a show/trial during a performance other My dog wanders away, e.g. on agility course or during heeling pattern (choose all that apply): in class at a show/trial during a performance other My dog is easily distracted by the environment, e.g. other dogs, noises, people, motion, etc (choose all that apply): in class at a show/trial during a performance other My dog "drifts off", becomes disconnected or disengaged from the handler (choose all that apply): in class at a show/trial during a performance other My dog shows stress behaviors such as yawning, lip-licking, scratching (but not itchy), avoids eye contact, especially when asked to perform (choose all that apply): in class at a show/trial during a performance other My dog barks, pulls, lunges at dogs, objects he is uncertain about, but can be interrupted or he recovers quickly (choose all that apply): in class at a show/trial during a performance other My dog is easily "over-excited" or aroused and is no longer in thinking/learning mode (i.e. gets the "zoomies", etc) (choose all that apply): in class at a show/trial during a performance other My dog is mildly responsive to sudden environmental changes (falling chair, person entering far end of room, etc) but recovers quickly (choose all that apply): in class at a show/trial during a performance other My dog is unable to focus or relax for even a moderate amount of time (choose all that apply): in class at a show/trial during a performance other Please describe the other circumstances or expand on any of the selected responses. BITE-FIGHT HISTORY Has your dog been in dog fights with household dogs or other dogs? YES NO Describe a typical "fight": Would it be more accurate to call these "discussions"? YES NO Do you know what started any of these fights? Describe: Did you see any mouth contact in these fights? YES NO Were there any injuries? YES NO Describe the injuries (tooth scrape, very shallow tooth poke, deeper tooth poke, bite and hang on, etc) On which parts of the body were the injuries? On which dog? Did either dog require a vet visit? Which dog? Has your dog ever air-snapped at you or at another person? Describe. Has your dog ever growled at you or at another person? Describe. Has your dog ever grabbed at you or at another person with his mouth and held on? Describe. Has your dog ever bitten you or another person? Describe. Did the bite require medical attention? YES NO TRIGGERS Describe your dog's behavior when on leash and he sees another dog (or some other trigger)? How does your dog react to an OFF-leash dog that approaches when your dog is on leash? What other things cause reactions? (cars, bikes, motorcycles, skateboards, skaters, joggers, children, heavy equipment, garbage trucks, cats, and so on) Describe. How close does your dog have to be before he reacts to any of these triggers? How long does it take your dog to show some self-control after a triggering event? How long does it take your dog to be really relaxed and comfortable after a triggering event? What does your dog do on a walk when there are NO triggers? What are your dog's signals that he is stressed, worried or uncomfortable? Is your dog reactive to any of his triggers at home? in the house? in the yard? at the windows? GOALS What are your hopes and goals for you and your dog in this course? What are your hopes and goals for you and your dog for performance or competition? Any other hopes or goals yo have for you and your dog? FINALLY . . . What are things you and your dog love to do together? What is something you really love about your dog? Anything else you would like to add?