Behavior Questionnaire

Full Name *

First Name Last Name

Phone Number *

Area Code Phone Number

Do you receive texts to this number? *

Yes No

E-mail *

What is the best way to contact you? *

Phone call Email Text Facebook Messenger

Physical Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

How did you hear about me? *

Dog's Name *

Breed or mix *

Where did you get your dog? Please include NAME of rescue, shelter or breeder if applicable. *

Why did you obtain this dog? (Companionship, watchdog, sport competition, playmate for current dog, etc) *

Dog's age: *

How long have you had your dog? *

If you got your dog as a puppy, how old was s/he when you brought him/her home? *

Is your dog spayed or neutered? *

Yes No Not Yet

Dog's sex: *

Male Female

Dog's weight *

Coat color: *

Do you use a crate with this dog? *

Yes No We have one but do not use it.

Has your dog ever bitten a person? *

Yes No

Did the injury require medical treatment?

Yes No

Describe the severity of the injuries inflicted:

Please explain the circumstances of the bite/s:

Is your dog motivated by food/treats? *

Yes Sometimes/Depends on the food/treat No

Is your dog motivated by toys? *

Yes Sometimes/Depends on the toy No

How do you exercise your dog? *

What equipment do you use to walk your dog? *

Regular, buckle collar Martingale/Limited slip collar Choke chain Prong/pinch collar Harness (regular or no-pull) Head harness (Halti, Gentle Leader, etc)

Do you walk your dog using a Flexi or retractable leash?

Has your dog ever worn an electronic/shock collar? *

No Yes, for training with me Yes, for training with a trainer Vibration only Invisible/Underground fence only I'm not sure

List any medications (including preventatives) your dog is currently on: *

Does your dog have allergies? *

What brand/s of dog food do you feed your dog? *

How many times a day is your dog fed? *

Dog's Name

Breed or mix

Dog's Age

How long have you had your dogs?

If you got your dog as a puppy, how old was s/he when you brought him/her home?

Dog's Sex

Male Female

Where did you get your dog? (ex: Rescue, breeder, friend, etc.)

Why did you obtain this dog? (Companionship, watchdog, sport competition, playmate for current dog, etc)

Is your dog spayed or neutered?

Yes No Not Yet

Dog's weight

Coat color:

Do you use a crate with this dog?

Yes No We have one but do not use it.

Has your dog ever bitten a person or other animal?

Yes No

Did the injury require medical treatment?

Yes No

Describe the severity of the injuries inflicted:

Please explain the circumstances of the bite/s:

Is your dog motivated by food/treats?

Yes Sometimes/Depends on the food/treat No

Is your dog motivated by toys?

Yes Sometimes/Depends on the toy No

How do you exercise your dog?

What equipment do you use to walk your dog?

Regular, buckle collar Martingale/Limited slip collar Choke chain Prong/pinch collar Harness (regular or no-pull) Head harness (Halti, Gentle Leader, etc)

Do you walk your dog using a Flexi or retractable leash?

Has your dog ever worn an electronic/shock collar?

No Yes, for training with me Yes, for training with a trainer Vibration only Invisible/Underground fence only I'm not sure

Does your dog have allergies?

List any medications your dog is currently on:

What do you feed your dog?

How many times a day is your dog fed?

Veterinarian (Vet's name & clinic name): *

Has your dog had any training? List trainer, location, etc) *

List any skills your dog has (sit, down, stay, etc) *

Does your dog (check all that apply):

Please list the top 3 behaviors you would like to teach your dog: *

How long have you been dealing with the issue/s? *

What/how have you tried to fix the issues? *

Have there been any major changes recently? (move, pet or person passed away, diet change, etc) *

Please list any other pets in the home (name, breed, age):

Names of other adults living in the home: *

Age/s of children who live in or visit home often: *

How much time does your dog spend home alone? *

Where does your dog stay when home alone? *

Where does your dog sleep at night? *

How does your dog/s respond to people they do not know coming into the home? *

Is there anything else you would like me to know about you or your dog/s?

I am interested in: *

Basics Program (3 sessions) $350 Manners Program (5 sessions) $500 Prodigy (8 sessions) $750

Program sessions expire 3 months from date of first session. No exceptions: *

I agree

I understand there is a $150 non-refundable deposit required to book a consultation (payable via Venmo, Cash App, or Zelle) & balance of program is due at consult:

I agree

What days/time frames would be best for you to schedule a consult? *

I understand that dog training and behavior modification is not without risk to myself, members of my family, guests, or my dog or other pets. I hereby waive my rights to any claim and release Jessica Hudson and Mobile Dog Training from any and all liability of any nature, for injury or damage which I or my dog may suffer, including specifically, but not limited to, any injury or damage resulting from the action of any dog, and I expressly assume the risk of any such damage or injury while attending any training session, function or event wherever the activity is taking place. In consideration of and as inducement towards the acceptance of my enrollment in lessons, I hereby agree to indemnify and hold Jessica Hudson from any and all claims, or claims by me, any member of my family or any other person accompanying me to any training session wherever they may be located arising out of any action by any dog, including my own, including but not limited to the responsibility for all damages, expenses and legal fees. I further indemnify and agree to hold harmless Jessica Hudson from any and all claims, or claims by any third party at any training session wherever they may be located arising out of any action by any dog, including my own, including but not limited to the responsibility for damages, expenses and legal fees.

Programs are prepaid or due in full at the first consultation unless otherwise agreed upon by both parties. Any returned checks are subject to a $35 bank fee and a $20 late fee. Cash, personal checks, Venmo, Cash App are accepted, PayPal accepted for behavior consult deposits.

Cancellations received 72 hours prior to scheduled appointment will be accepted without penalty.
Cancellations received less than 72 hours prior to scheduled appointment will be subject to a $35 rescheduling fee.
Cancellations received less than 24 hours prior to scheduled appointment will result in the forfeiture of that session, with no refund.
Cancellations due to inclement weather are not subject to penalty.

I have read and, by completing this form and clicking submit below, agree to abide by the aforementioned Waiver and Assumption of Risk and Agreement to Hold Harmless.

Mobile Dog Training Form

Dog 1

Dog 2 (Only if this dog needs training, as well)

Additional Information