Puppy/New Dog Registration

Client & Dog Information

Name (guardian #1) *

First

Last (guardian #1) *

Last

Chosen pronouns (if you'd like to share)

Name (guardian #2)

First

Last (guardian #2)

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 (guardian #1) *

Email Address (guardian #2)

How did you hear about me? *

Dog's Weight *

Dog's Breed *

Dog's Age (please list months or years) *

Dog's Sex *

Spayed/Neutered *

Yes

No

Date of Adoption/Purchase *

Adoption/Purchase Source (please be specific and list rescue or breeder name and location) *

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) *

Health Information

Vet Office/Vet's Name *

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

Current Medications & Reason for Medications (include name, dose, frequency) *

Most Recent Vet Visit and Results *

Important Medical History Notes *

May we share your training & behavior report with your veterinarian or other behavior professionals? (This is relevant for sending medication consult or other referrals and allows continuity of care between myself and your vet team.)) *

Yes

No

Physical Symptoms

Does your dog have any sound sensitivity to the following noises?

If yes, what their response is to these noises? (shakes, hides, runs away, seeks comfort, etc.) *

Type "NA" if not applicable.

Does your dog have any skin issues including ear infections, itchiness, red patches, foot chewing, hair loss or have an unpleasant smell? *

Type "NA" if not applicable.

Does your dog have any known mobility/joint symptoms like limping or yelping? Has your dog been diagnosed with a joint disorder by a vet? *

Type "NA" if not applicable.

Dog's Routine

Describe your dog’s daily routine. (wake up time, walks, feeding, naps, bedtime and other activities) *

What does your dog eat? Please be sure to specify what type of food/brand name (kibble, wet, raw, dehydrated), brand and how much food they eat and whether you use bowls or feeding toys. *

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

What kinds of toys, chews, etc. does your dog play with, and how often? When do they play with their 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 your dog, or had they done any before you got them? List the names of the trainers and any books or social media accounts that you have used for training. *

Describe the basic approach you have used 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 or activities would you like your dog to do related to this consult? (examples: feel safe around children, allow objects to be safely removed from him, sit at an outdoor cafe, walk through the park) *

Which is your top priority to discuss at the initial consult? (select only one) *

Fear or Aggression Toward Humans

Has your dog's mouth made contact with a person's skin or clothing (aside from puppy mouthing) at any time? *

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 in detail all bite incidents including dates, injuries and the scenario that led to the bite(s). *

Type "NA" if not applicable.

Familiarity to dog *

Person was known to the dog

Person was a stranger to the dog

Both strangers and familiar people have been bitten.

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 your dog's behavior over time? *

Type "NA" if not applicable.

What does your dog 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.

What does your dog do when strangers on walks (or outside the home) try to pet them? *

Type "NA" if not applicable.

Did any of the incidents involve: *

Did any of the incidents involve your dog 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 your dog 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 your dog react when on leash to other dogs? *

How does your dog react when off leash to other dogs? *

Have you noticed any escalation or change in your dog's behavior over time with other dogs? *

Type "NA" if not applicable.

Does your dog 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 your dog 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 your dog when you leave the house? *

Type "NA" if not applicable.

When did you first notice that your dog was anxious when left alone? *

Type "NA" if not applicable.

Does your dog behave differently when left with another dog or with another person? *

Type "NA" if not applicable.

Is there any place that your dog is comfortable being left alone, such as in the car? *

Type "NA" if not applicable.

Is your dog crate-trained? *

Where would you like to be able to leave your dog when you are not home, and for how long? *

When do your dog'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 you'd like to share about yourself or your dog?

Client & Dog Information

Health Information

Physical Symptoms

Dog's Routine

Training History/Reinforcers

Client Goals

Fear or Aggression Toward Humans

Fear or Aggression Toward Dogs

Separation Anxiety

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