Behavior Consultation Form

Household Information
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

City

Postal / Zip Code
Phone Number*

Area CodePhone Number
E-mail*
How did you hear about DogSpeak?*

Your Dog's FriendUnleashed by PetcoYour vetDog daycareSocial media (Facebook)Search engineOther
What is your preferred training time?*

Weekday afternoonsSaturday
What is your preferred method of communication?*
I may record sessions for educational or marketing purposes. If you would like to opt out, please select one of the following:

Do not use video or images of myself or my dog.You may use video or images of myself and my dog but nothing that includes other household members (especially children).You may use video or images of my dog where my face is not showing.I am fine with you using video or images from my sessions for this purpose.Other
List ages of any children in the household
Dog's Name*
List any other pets in the household
Veterinary Information
Vet Clinic*
Veterinarian
Vet Clinic Phone Number*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you discussed the problem behavior with your veterinarian?

YesNo
May I contact your veterinarian, if necessary?

YesNo
Dog Information
Age*
Breed*
Gender

Intact MaleIntact FemaleNeutered MaleSpayed Female
When did you acquire your dog?
Please describe your dog's history prior to acquisition:
Average amount of exercise per day
What does your dog do for exercise? (Check all that apply)

WalksBackyard playDog park or playdatesHikingFetchTug
What does your dog do for exercise?
Please list all activities that you consider exercise for your dog such as walks, runs, hiking, backyard play, Dog Park or playdates, fetch, etc. Please also include the intensity of play/exercise per activity.
Is Your Dog Current On All Vaccinations? (Please be prepared to present proof of vaccination at consultation)*

YesNo
Date of Rabies:*

MonthDayYear
Date
Date of Distemper (DHLP):*

MonthDayYear
Date
Please List Any Food Allergies or Medical Problems:*
Please include any resolved medical issues.
Diet Information
Dog Food
How many feedings/day?
How much does your dog eat?
Cups/feeding
What is your daily feeding routine? (Include treats, supplements, etc.)
Behavior Information
What is the primary behavior issue?*

How would you rate the severity of the issue?*

	1	2	3	4	5

1 is Minor or barely noticeable, 5 is Considering rehoming

Is this a chronic or intermittent issue?

ChronicIntermittent
How often does the behavior occur?
When did you first notice the behavior?
Does your dog exhibit any of the following behavior?*

Reactive towards strangersReactive to other dogsAnxietyShy or fearful behaviorGrowling or snappingGuards foodGuards non-food items (toys, people, locations)House soilingDestructiveNone of the above
Describe Any Unwanted Behavior In Detail:
What strategies have you used to address these issues?*
What do you hope to accomplish with private training?*
Describe any previous dog training:
What tools have you used with your dog? (Check all that apply)

Flat collarChoke chainProng collarElectric collarFixed leashRetractable leashLong line/leashHead halter (Gentle Leader, Halti, etc.)No-pull harness (Easy Walk, Sens-a-tion, etc.)Traditional harnessShake cansSpray bottleCrateClickerBaby gatesTreats
Do you use a crate?

YesNo
Does your dog like the crate?

YesNo
Have you previously used any aversives such as a leash correction, verbal scolding, or rollover?*

YesNo
If you answered yes, please give details:
Describe situation (out on walk, found accident in house), correction used, and dog's reaction (cowering, growl, etc.)
Has your dog's personality changed since first acquired? Please describe:
Have you trained your dog to wear a muzzle?

YesNo
Bite History
Has Your Dog Ever Bitten or Snapped at A Person?*

YesNo
If Yes, what were the circumstance?
Was it triggered by a certain type of person (stranger, children) or a specific situation (guarding food, being held, woken up, etc.)?
What was the severity of the bite?

Pre-Bite: snapping (air bite, no contact)Near-Bite: tooth contact on skin, but no punctureSkin puncture(s), single bite (all punctures shallower than the length of the canine tooth)Skin puncture(s), multiple bites (all punctures shallower than the length of the canine tooth)Single bite with punctures deeper than the length of the canine tooth (the dog bit and clamped down)Multiple bites with deep punctures or multiple attack incident
Has Your Dog Ever Bitten another dog?*

YesNo
If Yes, what were the circumstance?
Was it triggered by a certain type of dog (small, big, reactive) or activity (dogs at fence or in yard) or a specific situation (guarding food or toys)?
What was the severity of the bite?

Pre-Bite: snapping (air bite, no contact)Near-Bite: tooth contact on skin, but no punctureSkin puncture(s), single bite (all punctures shallower than the length of the canine tooth)Skin puncture(s), multiple bites (all punctures shallower than the length of the canine tooth)Single bite with punctures deeper than the length of the canine tooth (the dog bit and clamped down)Multiple bites with deep punctures or multiple attack incident
Additional Information
Is there any other information you would like to share or believe the trainer should know?
Should be Empty: