Intake Form

To be filled out after session has been scheduled.

Please fill out the following questionnaire so that we can have a better idea of what is happening for you and your dog.

Fields marked with a * are required.

GENERAL INFORMATION



















HOME ENVIRONMENT


Please list the people, including yourself, living in the household. Please include the ages of all children or grandchildren living in the home.



Please list the animals, excluding the people, in the household.














DOG'S BACKGROUND



Animal ShelterBreeder - newspaper ad/flyerBreeder - referralFriendPet StoreRescue OrganizationStrayOther:











DIET AND DAILY ROUTINE























TRAINING EXPERIENCE




Dog is placed into position manually.
Dog is lured into position.
Dog is shaped into position using a clicker or verbal marker like "yes!"
Behavior is captured using a clicker or verbal marker.
Dog is punished with a leash correction for not obeying a command.
Dog is punished using an electric collar for not obeying a command.
Dog is verbally punished for not obeying a command.
Dog is ignored for not responding to a cue.











YesNo

DOG'S BEHAVIOUR





YesNo


YesNo


YesNo



DOG'S MEDICAL HISTORY



YesNo


YesNo




YesNo

PROBLEM BEHAVIORS


Are there behaviors that you would rather your dog didn't do? Please be specific and list them in the order of your priorities for training behavioral changes. If you have more than five major problems, just use the last box for more than one problem. Leave blank if you already listed these above.






Choose the following option that best describes your situation.


YesNo

YesNo


YesNo





YesNo

YesNo

Describe in detail the most recent event of this behaviour happening:



Describe in detail the first time you remember this behaviour happening:




SURVEY OF AGGRESSIVE BEHAVIORS


Please fill out this section even if you do not currently have any concerns about your dog’s behavior toward people. This information is essential for me to evaluate and consider before I decide whether the type of training plan I might offer is advisable or feasible.

How does your dog react under the circumstances described below? Please use one of these behavior descriptions (if applicable) to characterize the worst of your dog’s reactions. If you do not feel comfortable doing some of these things, by all means, don't do them! Some of the things on this list are not recommended for any dog.

NA - not applicable

NR - no negative reaction

BR - bark or whine

GR - growl

SL - snarl/bare teeth

SB - snap/bite






































YesNo












Thank you for taking the time to complete this form. We look forward to working with you. Now go get yourself something tasty as a reward!

This Canine Behavior Questionnaire and Aggression Screen have been expanded and modified by Cindy Peacock from Grisha Stewart, who modified it from the original “Canine Behavioral History” form published by the Cornell University College of Veterinary Medicine. Animal Behavior Clinic, College of Veterinary Medicine, Cornell University Ithaca, NY 14853-6401. The Cornell University’s original form may be found at: http://www.vet.cornell.edu/abc/canine_history.htm

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