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?

What is your preferred training time?

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:

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?

May I contact your veterinarian, if necessary?

Dog Information

Age

Breed

Gender

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)

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 send an electronic copy to DogSpeak prior to consultation)

Date of Rabies:

Date

Date of Distemper (DHLP):

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?

How often does the behavior occur?

When did you first notice the behavior?

Does your dog exhibit any of the following behavior?

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)

Do you use a crate?

Does your dog like the crate?

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

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?

Bite History

Has Your Dog Ever Bitten or Snapped at A Person?

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?

Has Your Dog Ever Bitten another dog?

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?

Additional Information

Is there any other information you would like to share or believe the trainer should know?