Advanced Training and Behavior Modification Customer Intake Training Contact Information Name * Name First First Last Last Email * Phone * Full address * Availability Check all that you are interest in Consultation Private lesson(s) Play and Train visits Reactivity (Counter Conditioning) Walks Day Training Board and Train Dog Information Dog's name Dog's age How much does your dog weight? Dog's age when adopted or purchased Sex Female Male Check if spayed/neutered Breed or type General Information Describe three things you like about your dog or enjoy doing with him/her Check if vaccinations are current What is the main problem or concern? Please check off any issues Not housebroken Urinates when excited or afraid Jumps up Overactive/doesn't settle easily Nervous or easily stressed Fearful or shy Nuisance barking Demanding barking Chews destructively Bolts through open doors Pulls on leash Doesn't come when called Unresponsive to name or commands Inattentive/short attention span Play biting/mouthing Steals food or objects Guards food, toys or objects Guards people Guards space or territory Aggressive toward people Aggressive toward dogs Growls at family members Has injured one more person Has injured one or more dog Separation Anxiety How often is the main problem occurring? Once a month or less No more than once a week Several times a week Every day Multiple times per day This problem is increasing in Frequency Intensity Duration None of the above What have you done to address or correct the above issues? Please indicate specific tools and methods if any Were these methods effective? If you have worked previously with a trainer, behavior consultant, or veterinary behaviorist, please indicate when and what that work entailed Are you concerned about losing physical control of your dog? (Leash being pulled out of hands, being knocked over, etc.) What are your most urgent priorities? What are your long-term goals for your dog? Please check all the things your dog loves to do Go for walks play fetch play tug Run with you Go to the dog park Meet new people Meet new dogs Cuddle Get touch, scratch or pets Receive treats General Information How many adults reside in your household? How many children? What other pets do you own? How many visitors come to the home on average each week? Is this your first dog? Where does your dog sleep? Do you crate your dog? If so, when and how does he tolerate it? Do you ever confine your dog to a room or area of the house? How much time does your dog spend loose in the home unattended? Is your dog social with new people? Is your dog social with other dogs? How much social interaction with other dogs has your dog had, either on-leash or off? Do you visit dog parks or send your dog to daycare? If so, where and how often? Has your dog ever boarded at a boarding facility? Did you get any feedback from the facility about your dog's stay? Describe your dog's play style or manner of interaction with other dogs? Check off any commands or skills you have taught Sit Down Wait/Stay Come Heel Off Leave It Touch Watch Me Drop It/Out Ok/Free Back Go Away Hand Signals Loose-leash Manners What equipment do you currently use to walk your dog? Is there any equipment you've used in the past? What do you feed your dog? Aggression History Check any known or suspected aggression triggers Stranger approaching Stranger passing Direct or heavy eye-contact Approach or physical contact while eating Approach or physical contact while resting Approach or physical contact while having a toy Verbal correction Leash correction Other physical correction or punishment Approach or presence of children or infants None If your dog has problems with guarding, please explain Does your dog have any aggression issues or have bitten any person or dog? If so, please explain Additional Information Does your dog suffer from any allergies or medical conditions? How did you find K9 Satisfaction? Please provide any additional information If you are human, leave this field blank. Submit
