Customer Intake Form NOTICE: Unfortunately, we are booked and will not be accepting new customers until September 2022. Sorry for any inconvenience this may cause. We wish you the best on your training journey. Customer Intake Form Contact Information Name * Name First First Last Last Email * Phone * Full address * Availability * Dog Information Dog's name * Dog's age Dog's age when adopted or purchased Sex * Female Male Check if spayed/neutered Breed or type * Name and location of breeder or rescue organization Describe three things you like about your dog or enjoy doing with him/her Vaccinations Check if vaccinations are current Reason for Behavior Evaluation What is the main problem or concern? Please check off any additional 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 Other Are you concerned about losing physical control of your dog? (Leash being pulled out of hands, being knocked over, etc.) Paragraph * If your dog has problems with guarding, please explain If aggressive, please explain If has bitten or caused injury to a person, please explain If has bitten or caused injury to another dog, please explain If other, please explain Describe the most serious incident that has so far occurred (please note when this happened) Describe the most recent incident 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 What are your most urgent priorities? * What are your long-term goals for your dog? * How did you find K9 Satisfaction? Household 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? Do you have a yard? 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? How did you choose your current dog? General History Do you know or were you given information regarding your dog's parents, litter-mates, or early history? 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 If you have trained with a food marker (ex: a clicker, "yes!", or "good"), please indicate it here If you have trained with a release word (ex: "free," "okay," or "break"), please indicate it here What equipment do you currently use to walk your dog? * Is there any equipment you've used in the past? Is there any equipment you are interested in using in the future? Health History What do you feed your dog, how often, and how much? * How much does your dog weight? * Does your dog suffer from any allergies or medical conditions? * Aggression History Does your dog have any aggression issues or have bitten any person or dog? If so, please explain * 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 Additional Comments Please provide any additional information If you are human, leave this field blank. Submit
