Client Registration Form - Behavior Consultation

Client & Dog Information

Name *

First

Last *

Last

Chosen pronouns (if you'd like to share)

Do you have any education or professional experience in psychology, applied behavior, human or veterinary medicine or animal behavior? If so, please explain here. *

N/A if not applicable.

Cell Phone (numbers only, no dashes) *

Dog's Name *

What's your favorite thing about your dog? *

I'd love to see your favorite picture of your dog! Share it here.

Maximum file size: 52.43MB

Address *

Address

City

State/Province

Zip/Postal

Country

Email Address *

How did you hear about us? *

Weight/Breed/Age/Sex *

Date of Adoption/Purchase *

Adoption/Purchase Source *

Household Information - HUMANS (please list everyone who lives in the home -include ages of minors) *

Household Information - ANIMALS (please list all cats/dogs or other animals your dog interacts with: include ages, species, breed, weight, how long in the home and whether they are spayed/neutered) *

Emergency & Health Information

Vet Office/Vet's Name *

Vet's Phone Number (numbers only no dashes) *

Spayed/Neutered *

Yes

No

Current Medications & Reason for Medications *

Most Recent Vet Visit and Results *

Important Medical History Notes *

May we share your training & behavior report with your veterinarian or other behavior professionals? *

Yes

No

Dog's Routine

Describe your dog’s daily routine. Please be sure to specify what type (kibble, wet, raw, dehydrated)/brand and how much food they eat. *

What does (Spot) do when you’re gone from the house? Do you have video cameras to know for sure what (Spot) does or are you guessing? *

What kinds of toys, chews, etc. does (Spot) play with, and how often? When does he/she play with his/her toys? *

What kind of gear do you use with your dog, both for training and walking (please specify collar type (flat, martingale, prong, choke, other? and/or harness (front or back clip?) *

Do you have a fence? If so, what kind (chainlink, solid, electric) and how tall? *

Training History/Reinforcers

Have you done any training with (Spot), or had he/she done any before you adopted him? Where did you do the training? Can you describe the basic approach you learned to train your dog? Did you feel you got the results you were looking for? *

What are your dog's favorite activities? *

What are your dog’s favorite foods or treats? Any food allergies? *

Client Goals

What skills would you like your dog to do? (examples: come when called, walk on a loose leash, allow objects to be safely removed from him) *

What activities would you like to be able to do with your dog? (examples: sit at an outdoor cafe, walk through the park) *

Fear or Aggression Toward Humans

Has (Spot's) mouth made contact with a person during any of the incidents? *

Yes

No

If yes, what is the worst result that has occurred?

1) Snap

2) Contact with zero damage

3) 1-4 shallow punctures

4) 1-4 deep punctures and/or bruising

5) Deep bi-directional tears

6) Multiple 4s or 5s

Fatality or mutilation

Not applicable

Bite levels as defined by Dr. Ian Dunbar

Describe the incident(s) you are concerned about. *

Type "NA" if not applicable.

Familiarity to dog *

Known to the dog

Strangers to the dog

N/A - there have been no bite incidents

Have you noticed anything similar about the situations or people involved across the incidents? (examples: all men, all at the front door, all while on leash, etc.) *

Type "NA" if not applicable.

Have you noticed any escalation or change in (Spot’s) behavior over time? *

Type "NA" if not applicable.

What does (Spot) do when strangers come into the home? (example: barks and approaches, tail down or avoids and hides or enthusiastically greets with loose body language) *

Type "NA" if not applicable.

Did any or could any of the incidents have involved (Spot) protecting: *

Did any of the incidents involve (Spot) being: *

Did any of the incidents involve someone: *

Changing positions (sit to stand, stand to sit, etc.)

Up high (on a ladder, etc.)

Re-entering the room or reappearing

Partially obstructed (behind a wall, etc.)

Carrying something (large bag, backpack, groceries, etc.)

Departing (exiting or walking away)

OtherOther

None or N/A

Fear or Aggression Toward Dogs

Has (Spot's) ever injured another dog, requiring vet care (shaving, suturing and/or antibiotics)? *

Yes

No

If yes, describe in detail the incident(s) and injuries. Were dogs leashed or unleashed? *

Type "NA" if not applicable.

Familiarity to dog *

Known dog on leash

Unknown dog on leash

N/A - there have been no bite incidents

How does (Spot) react when on leash to other dogs? *

How does (Spot) react when off leash to other dogs? *

Have you noticed any escalation or change in (Spot’s) behavior over time? *

Type "NA" if not applicable.

Does (Spot) resource guard valuable items from other dogs? *

If yes, which items? *

If yes, which of these behaviors have you noticed occur just before an incident? *

Separation Anxiety

Which of these signs of anxiety does (Spot) display in relation to begin left alone? *

Pre-departure anxiety (shadowing, whining, pacing, circling, etc.)

House soiling (when normally housebroken)

Excessive barking or whining

Chewing or scratching around doors and windows

Refusing food while alone (please list foods tried:)Refusing food while alone (please list foods tried:)

Self mutilation (bloody paws, excessive licking, etc.)

Extended or anxious greeting upon return escape artistry

OtherOther

None of the above

Where do you leave (Spot) when you leave the house? *

Type "NA" if not applicable.

When did you first notice that (Spot) was anxious when left alone? *

Type "NA" if not applicable.

Does (Spot) behave differently when left with another dog or with another person? *

Type "NA" if not applicable.

Is there any place that (Spot) is comfortable being left alone, such as in the car? *

Type "NA" if not applicable.

Is (Spot) crate-trained? *

Where would you like to be able to leave (Spot) when you are not home, and for how long? *

When do Spot’s signs of anxiety first begin? *

Do you need any disability-related accommodations to fully participate in this consultation or future training? For example, closed captioning for Zoom? Please feel free to share any information you are comfortable sharing.

Anything else we missed you'd like to share about yourself or your dog?