Client Registration Form – Separation Anxiety This form is best completed on a computer, not a mobile device. Please take your time and be as thorough and honest as possible. The more information we know ahead of time, the better prepared and efficient we can be to help you. Separation Anxiety Client Registration Form and Training Contract Client & Dog Information Name * First Last * Last Chosen pronouns (if you'd like to share) Do you have any education or professional experience in animal behavior, applied behavior, psychology or human or veterinary medicine? If so, please explain here. * Cell Phone (numbers on, no dashes) * Dog's Name * What's your favorite thing about your dog? * We'd love to see your favorite picture of your dog! Share it here. Drop a file here or click to upload Choose File Maximum file size: 52.43MB Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email Address * How did you hear about me? * 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) N/A if no other animals * Health Information Vet Office/Vet's Name * Vet's Phone Number * Spayed/Neutered * Yes No Current 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. Do you have a fence? If so, what kind? * 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?) * Training History/Reinforcers What are your dog's favorite activities? * 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? * Physical Symptoms Does your dog have any sound sensitivity to the following noises? * Thunder Fireworks/firecrackers Vehicles backfiring Trucks/Busses Beeps OtherOther My dog has no noise sensitivities. 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. Does your dog have any hesitation doing the following? * Walking across slippery surfaces Getting into/out of car Getting on/off furniture Being harnessed Getting up from a resting position Have leg lifted (for paw wiping or putting on harness) Sitting (you think your dog "isn't listening" when asked to sit) Sitting or lying down on hard surfaces Getting comfortable lying down (circles first, looks for a good spot, groans/grunts once they lie down) Being startled awake OtherOther N/A Does your dog have any of the following? * Inconsistent bowel movements Soft stools/diarrhea Inconsistent eater (doesn't eat whole meal in one sitting) Picky eater (needs to be coaxed to eat with add-ons or hand feeding) Sensitive stomach (gets upset tummy or diarrhea with small diet changes) Skips meals Regurgitating/vomiting food Vomiting bile Anal gland issues Licks people, objects or dog's own body Other GI symptoms N/A Separation Anxiety Which of these signs of anxiety does (Spot) display in relation to begin left alone? * Self mutilation (bloody paws, excessive licking, etc.) House soiling Pre-departure anxiety (shadowing, whining, pacing, circling, etc.) Chewing or scratching around doors and windows Excessive barking or whining Extended or anxious greeting upon return escape artistry Refusing food while alone (please list foods tried:)Refusing food while alone (please list foods tried:) None of the above When do Spot’s signs of anxiety first begin? * Shower Dressing Shoes Bag Keys OtherOther None of the above 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? * When did you first notice that (Spot) was anxious when left alone? * Any recent life changes (baby, move, construction, marriage/divorce, death, etc.)? * Does (Spot) behave differently when left with another dog or with another person? * Is there any place that (Spot) is comfortable being left alone, such as in the car? * Is (Spot) crate-trained? * Is (Spot) friendly with other dogs off-leash? * Is (Spot) friendly with strangers? * Where would you like to be able to leave (Spot) when you are not home, and for how long? * 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? Submit If you are human, leave this field blank.
