Zippity Do Dog Training Form

Reactive Dog and Behavior Form

Thank you for taking the time to tell me more about your dog! This form is for Reactive Dogs and Behavioral issues only. An in-person consultation will be required for your case. Before filling out this form please be sure to verify that you are in my service area and what my current availability is.
Full Name

First Name Last Name
Email
example@example.com
Phone Number

- Area Code Phone Number
Do you receive texts

Yes No
What is the best way to reach you

Phone call Email Text Facebook Messenger

Physical Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

How did you hear about me?
What is your dog's name?
Dog's age
Breed or mix
Dog's sex

Male Female
Is your dog spayed or neutered?

Yes No Not yet
Dog's weight
Coat type and color
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.)
How long have you had this dog?
If you got your dog as a puppy, how old was s/he when you brought him/her home?
Do you use a crate for this dog?

Yes, loves the crate No longer uses crate Attempted crate training No, prefer not to use a crate Would like to crate train, not sure how to get started No, my dog hates a crate
Is your dog social with unfamiliar people?

Seems to love just about everyone Good with unfamiliar women Good with unfamiliar med Good with unfamiliar children Selective Tolerant (okay in their presence but doesn't like to be touched by strangers Scared, avoids strangers Aggressive (barks, growls, lunges, etc)
Is your dog social with unfamiliar dogs?

Seems to love just about every dog Good with big dogs Good with small dogs Good when off-leash only Selective Tolerant (okay in their presence, just doesn't want to be sniffed) Not sure
Has your dog ever bitten anyone?

No Not to my knowledge I'm not sure if it was play or aggressive My dog has growled but never bitten Yes, but it left no mark Yes, the bite bruised the skin Yes, the bite left a shallow puncture Yes, the bite left multiple punctures Yes, my dog has bitten multiple times
Describe the severity of the injuries inflicted:
Did the injury require medical treatment?
Please explain the circumstances that occurred just before and around the time of the bite:
Is your dog motivated by food/treats?

Yes No
Is your dog motivated by toys?

Yes No
How do your exercise your dog?
What other enrichment opportunities does your dog get during the day?

Kongs Food Dispensing Toys Puzzle Toys Chew Toys None of the above
What equipment do you use to walk your dog?

Regular Flat Buckle Collar Martingale/Limited Slip Collar Choke Chain Prong/Pinch Collar Harness (regular or no pull style) Head Harness (Halti, Gentle Leader, Etc.) Muzzle
Do you (or a dog walker) walk your dog using a Flexi Leash or other 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 and herbal remedies) your dog is currently on:
Does your dog have allergies?
What brand of food do you feed your dog?
How many times per day is your dog fed?
Food drive

High Medium Low Depends Not sure No interest when food or treats are offered
Date (approximate is okay) of last vet visit and reason:
Additional Information
Veterinarian (Name & Clinic/Hospital)
Has your dog had any previous training? List trainer name and location or self.

Yes, group puppy class Yes, group class adult Yes, private lessons Yes, sent to board & train Informal training at home Nope, but ready to learn Currently in group class
Who was the trainer?
List any skills your dog already has (sit, down, stay,etc)
Are these skills 100% reliable under any circumstances?
Check the issues you would like to discuss with the trainer:

Submissive/Excitement Urination Pulling on leash Demands attention Stealing food Resource guarding (food, toys, people, space) with dogs Resource guarding (food, toys, people, space) with people Runs away (won't come when called) Aggressive behavior with people Aggressive behavior with dogs Separation anxiety Anxious behavior Excessive barking Excessive energy Behavior with guests Jumping on people Destructive behaviors Houe training Barks on leash at other dogs Barks on leash at other people Barks on leash at moving objects (cars, bikes, skateboards, etc) Digs in yard Mouthing Obsessive Compulsive behaviors (ie: spinning, light/shadow chasing) Other
List the top three behaviors that you would like to change:
How long have you been dealing with the issues noted above?
How have you tried to fix these issues?
How do you reinforce desirable behaviors?

Praise Food rewards Toy rewards Life rewards (walks, sniffing, playtime)
How do you address undesirable behaviors? (jumping, barking, etc.)

Interrupt Redirect Verbal reprimand (scold, say "no") Correction with training collar Physical reprimand Other
Have there been any significant changes recently in your dogs life? (a move, pet or person passed away or moved out, diet changes, etc.)
Please list any other pets in the home (name,breed,age)
Who lives in the home full time/part time? Include ages of children if applicable.
How much time does your dog spend home alone?

My dog is never alone 1-3 hours 4-6 hours 7-9 hours 10-12 hours or more
Where does your dog stay when home alone?
Where does your dog sleep at night?
Is your dog allowed on furniture

Couches Human beds Only by invitation Only on certain furniture No No but my dog does it anyway Yes, my dog is allowed on all furniture
Is there anything else, not covered in this intake form, that you would like me to know?
I am interested in (check all that apply):

Consultation $75.00 Specific Behavior Modification Behavioral Evaluation/Assessment
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 Lee Desmarais and Zippity Do Dog Training and Behavior Modification 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 Lee Desmarais 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 Lee Desmarais 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 due to inclement weather are not subject to 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.
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.
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Reactive Dog and Behavior Form

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