Stranger Danger Form (All applications are pending review. We will contact you via phone.)

Owner Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

Dog's Name *

Breed *

Color *

Age of dog now *

Weight *

Sex *

M
F

Is your dog

Spayed
Neutered

Age of neutering

Any behavioral changes following neutering?

Name of veterinarian

Name of hospital

Date of last veterinary exam

Any medical issues

List any current medications or supplements

List any previous behavior medications that have been tried including dose and dates when the medications were started and stopped.

Please describe your dog’s problem behavior(s) that led you to seek out this program.

At what age did the behavior start?

How long does each incident last when it occurs?

How often does it occur?

Have there been any changes in the pattern, frequency, intensity, or length of incidents from the first time your dog exhibited the behavior(s) to the present?

Yes
No

Are there any specific environmental conditions that trigger the behavior (who is present? What is going on in the environment before and after?)

Can your dog be verbally or physically interrupted when engaged in the problem behavior?

Yes
No
Sometimes

Please give a detailed description of what led you to seek out help and describe the incidents.

How do you respond when your dog displays the problem behavior?

Where did you get your dog?

How old was your dog when you brought them home?

Do you have any information about your dog’s history before you acquired him? If so, please explain.

Do you know if you dog’s parents or siblings engaged in similar behaviors or other abnormal behaviors?

List people living in the house with the dog. Include children and their ages.

List animals in the household. Species, breed, age, sex, and whether or not they are neutered. Please indicate which of these animals were living in the house when the dog was acquired.

Describe interactions between the animals in the household.

Describe interactions between your dog and family members.

Describe behavior of your dog in the veterinary office during examination.

Type of food?

Frequency of feeding?

Table food/scraps/treats (list all).

Does your dog exercise daily?

Yes
No

Where, when, and how?

Time spent playing with owner. Describe activities which take place.

Do you have a fenced in yard or an Invisible Fence? If yes, which one?

Describe time spent playing with other animals.

What type of collar or harness do you use?

When training, what is your dog’s favorite reward?

Have you attended training sessions with your dog? Please describe the class.

Have you previously enlisted the help of a trainer, behaviorist, or veterinarian for help with this behavior problem?

Yes
No

What recommendations were you given?

Was there any improvement?

Does your dog offer trained cues willingly? If yes, please list the trained behaviors they know the best.

Please list situations where your dog is less likely to offer cues if any*

Does your dog have any known bites throughout their lifetime? If yes, please describe the severity, number of known bites, location of the bite, if it required medical attention, and any other background information about what was going on in the environment at that time and how the humans involved responded.

What are three things you love about your dog?

What has led you to seek out help now?

Is there anything else you want us to know about your dog?

How would your life be improved if your dog’s behavior could change?

How would your dog’s life improve if the behavior changed?

Are your prepared to commit to implementing a behavior plan daily and managing for your dog for their lifetime to prevent incident?

Will all family members be on board?

Are you prepared to make an appointment with a veterinarian at any point in the process if needed to rule out underlying medical causes or have a consult about supportive medications?

Yes
No

Please make sure all decision makers are present for the intake interview. Thank you, and I look forward to communicating with you!