Behavior Intake Form Training QuestionnairePlease enable JavaScript in your browser to complete this form. This questionnaire is only required for a Behavior Consultation, Private Training or when requested by the Training Department. Name *FirstLastEmail *PhoneDog's Name *Breed of DogAge of DogPrevious HistoryHow old was your dog when you adopted him/her and from where did you acquire the dog? *Provide any information on previous owners or home(s), if known: *Household InformationAre there any children under 18 in your householdYesNoAges of childrenTell us about any other pets in the household that this dog interacts with: species, breed, age, gender, and how they interact:Let us know about any of the following events in the recent past. Check all that apply. *Moved houseDeath or illness of family memberMarriage/Divorce/SeparationNew babyOtherNonePlease provide details about the item(s) you have checkedHealthDiet: What do you feed your dog? Please be specific about brand and type (canned/dry): *Is your dog currently taking any medication or supplements?Tell us about your dog's overall health, including any recent changes or events. *Problem BehaviorIs there a specific behavior that brought you to usAggression toward peopleAggression toward dogsAnxietyBarking in house/crateBarking outside/on leashChasing (cat, kids, etc.)ChewingCounter surfingFearfulHousetrainingJumping/pulling/rude behaviorLunging on leash (reactivity)Obnoxious or attention seeking behaviorPuppy nipping/bitingResource guardingSeparation anxietyShynessOtherRate the severity of aggression Severity of aggression: 0 Use the slider to choose a level between one and fiveRate the severity of the nipping/biting Severity of nipping/biting: 0 Use the slider to choose a level between one and fiveWhat is your dog guarding?Rate the severity of the guarding Severity of guarding: 0 Use the slider to choose a level between one and fiveFirst Occurance *How long has your dog been exhibiting this behavior?Describe the problem behavior that brought you to us. Be as detailed as possible: *LocationIs there a specific location where this behavior occurs more than others? If so, where?Time FrameIs there a specific time of day when this behavior is more likely to occur? If so, when?Who has been present when the dog exhibits problematic behavior? What interactions did they have with the dog before and after the occurrence? *Is there anything else you can think of that may be contributing to your dog exhibiting this behavior, or anything else you'd like us to know about your dog.What have you done to try to correct this behavior? Please be specific: *Has your dog ever bitten anyone? *YesNoExplain the circumstances, the severity of the bite(s), and whether it required medical attention.More InformationWhat are your goals for your dog?What do you like? *Tell us 3 things you like about your dog.Please tell us which program(s) you are interested in to address your dog's behavior. *Boarding SchoolPrivate TrainingBasic TrainingNot sure yetWho referred you to us for training/behavior modification? *VeterinarianTrainerBehavior consultantFriendI am an All Dogs Gym clientOtherName of referral sourceIs there a recent incident that lead to your contacting us at this time? If so, please describe.EmailSubmit
