Owner's Name*

Pet's Name*

Breed (use "mixed" or "unknown" if applicable)*

Sex (please indicate if intact or altered)*

Current Age of Dog (use best estimate if unknown)*

Owner's Contact Method

E-Mail (required for online classes and behavior plans)*

Best Phone Number for Contact*

Pet's Regular Veterinarian

Doctor's Name

Name of Practice*

Phone Number

Behavioral History

Describe your primary concern regarding your pet's behavior.

List any additional behavioral concerns, from the most concerning at the top to the least concerning at the bottom.

What are your SHORT term goals for your dog (within the next 3-6 months)?

What are your LONG term goals for your dog?

How old was your dog when you first observed problematic behavior (related to your primary concern)?*

Please describe the three most recent incidents of concern involving your dog. (Describe as fully as possible, including where it occurred, who was present, what known triggers were present, the outcome, and what you did in response. If the dog made contact with anyone with his teeth in this incident, be sure to include that information and how severe the bite was - no injury, band-aid level injury, puncture, multiple punctures, extensive bruising, etc.)

Most Recent Incident (please include date or approximate date)

2nd Most Recent Incident (please include date or approximate date)

3rd Most Recent Incident (please include date or approximate date)

Previous Interventions

Please check all interventions previously attempted with regard to the primary concern for this pet.

Was there anything else that was tried? (if other was checked above, please describe here.)

Skills or Desireable Behaviors Your Dog Can ALREADY Perform Reliably (reliably means at least 80% of the time, even with mild to moderate distractions or in unfamiliar locations)

Behaviors or Skills Your Dog Can Do Now*

Additional Household Information

Training Experience (Please check what is MOST applicable to the primary owner / handler.)

Household Make-Up (List all other human household members, including name, age and role they play in caring for the dog.)*

Describe a routine schedule for household, including approximate times of feeding, exercise and other dog related tasks.

Does your dog have any medical issues? (Describe nature and current treatment, if any. Be sure to include any special diet or exercise restrictions.)

Other

Is there anything else about your dog that you'd like us to know or feel that it is important for us to know?