Behavior Consultation Intake Form

Client Name

Patient Name

1. How old was your pet when you brought them home?

2. Where did you get your pet from? (Breeder/Shelter/Rehome etc.)

3. If your pup is a rescue/adoption, describe what you know about his/her history prior to you:

4. If you brought your pet home as a puppy/kitten, did you meet the parents? If so, what were they like?

5. Why did you/your family pick this dog?

6. What was your pet's early socialization experience (from 3 weeks to 6 months old), if they were a recue, please write “unknown”.

7. What diet does your pet currently eat? Brand name and flavor/type.

8. Please describe your normal routine with your pet:

9. Percent of time indoors / outdoors?

10. Where does your dog sleep?

11. Where are they kept when you’re gone during the day?

12. How does your pet behave when home alone?

13. How do they behave when you return?

14. Do they attend any of the following?

Daycare

Dog Parks

Boarding Facilities

If so, how do they do while there?

15. How active is your pet?

	1 (inactive)	2	3	4	5 (marathon runner)
.

16. List all human members in household: (Name, Gender, Age (of children), Relationship to you)

17. How does your pet feel about the members of the home, do they get along well with everyone? Avoid anyone?

18. Has your pet ever barked, growled, bitten or attempted to bite anyone in your home? If so please describe the incident, what happened before, during and after.

If there was a bite, did it make contact or break skin?

Was the bite reported?

Yes

No

19. List & describe any other animals in the household (species, breed, age, sex)

20. How does your pet feel about the other animals in the house?

21. Has there ever been any fighting between any of the animals in the house? If so, please describe what happened before, during and after.

1. Is your pet intact or altered?

Intact male

Intact female

Neutered male

Spayed female

2. How old was your pet when they were spayed or neutered? Did you notice any behavior changes before or afterwards?

3. Does your pet currently have any diagnosed medical conditions? If so, please list them and the date of diagnosis:

4. Is your pet currently taking any medications? If so, please list them with the dosage, frequency, and route of administration.

5. Does your pet tolerate taking medications?

6. Has your pet had any negative or undesired reactions to medications? If so, please describe them.

7. Has your pet had any prior medical concerns or diagnoses? (Ear infections, Injury, skin issues, etc.)

8. Has your pet ever struggled with Intermittent or consistent GI upset (Diarrhea, Vomiting)

Yes

No

9. What is the date of your pet's most recent rabies vaccination?

1. Is your pet house-trained?

Yes

No

Mostly but accidents happen

Other

2. Crate trained?

Yes

No

3. What behaviors does your pet know and reliably perform when asked?

4. Can they perform these behaviors when outside the home or in new areas?

5. What type of rewards does your pet enjoy the most? Check all that apply.

Treats/food

Praise Petting

Toys

Other

Have you worked with a trainer previously?

Yes

No

Name of company/trainer:

If so, please describe what you learned and how your pet responded to it.

How much time do you have to devote to training daily?

Less than 5 minutes

5-10 minutes

15-20 minutes

30+ minutes/day

8. Have you ever used any of the following training tools?

E-collar

Bark collar

Prong collar

Choke chain

Gentle leader

Clicker

How would you rate your pet's general anxiety level?

	1 - no anxiety, calm and relaxed	2	3	4	5 - constant worry/stress
.

2. For the questions below, please mark how best describes your dog’s response to these situations. With 1 being calm, loose or wiggly body and 5 being stiff, tail tucked or hackles razed, barking/growling/lunging or attempting to get away

	1	2	3	4	5
New people in the home
Other dogs on walks
Other people on walks
Bicycles
Wild animals
Loud noises
New items in the home

3. Has your pet ever Growled at, snapped at or bitten someone?

Yes

No

If so, please explain what happened before, during and after the event, if a bite happened did it break skin? Did it require medical attention?

Was the incident reported?

Yes

No

4. Has your pet ever growled at, snapped at or bitten another dog?

Yes

No

If so, please explain what happened before, during and after the event, if a bite happened did it break skin? Did it require medical attention?

Was the incident reported?

Yes

No

5. Has your dog every shown signs of resource guarding?

Yes

No

If yes, Please explain the situation:

1. What is the primary behavior concern that prompted this visit?

2. How frequently is the primary behavior of concern happening? Check all that apply.

Multiple times per day

Once per day

A few times per week

Once a week

A few times a month

Once a month

Less than once per month

Other

Behavior Consultation Intake Form

Client Name

Patient Name

General background information about your pet

1. How old was your pet when you brought them home?

2. Where did you get your pet from? (Breeder/Shelter/Rehome etc.)

3. If your pup is a rescue/adoption, describe what you know about his/her history prior to you:

4. If you brought your pet home as a puppy/kitten, did you meet the parents? If so, what were they like?

5. Why did you/your family pick this dog?

6. What was your pet's early socialization experience (from 3 weeks to 6 months old), if they were a recue, please write “unknown”.

7. What diet does your pet currently eat? Brand name and flavor/type.

8. Please describe your normal routine with your pet:

9. Percent of time indoors / outdoors?

10. Where does your dog sleep?

11. Where are they kept when you’re gone during the day?

12. How does your pet behave when home alone?

13. How do they behave when you return?

14. Do they attend any of the following?

If so, how do they do while there?

15. How active is your pet?

Household Information

16. List all human members in household: (Name, Gender, Age (of children), Relationship to you)

17. How does your pet feel about the members of the home, do they get along well with everyone? Avoid anyone?

18. Has your pet ever barked, growled, bitten or attempted to bite anyone in your home? If so please describe the incident, what happened before, during and after.

If there was a bite, did it make contact or break skin?

Was the bite reported?

19. List & describe any other animals in the household (species, breed, age, sex)

20. How does your pet feel about the other animals in the house?

21. Has there ever been any fighting between any of the animals in the house? If so, please describe what happened before, during and after.

Medical History

1. Is your pet intact or altered?

2. How old was your pet when they were spayed or neutered? Did you notice any behavior changes before or afterwards?

3. Does your pet currently have any diagnosed medical conditions? If so, please list them and the date of diagnosis:

4. Is your pet currently taking any medications? If so, please list them with the dosage, frequency, and route of administration.

5. Does your pet tolerate taking medications?

6. Has your pet had any negative or undesired reactions to medications? If so, please describe them.

7. Has your pet had any prior medical concerns or diagnoses? (Ear infections, Injury, skin issues, etc.)

8. Has your pet ever struggled with Intermittent or consistent GI upset (Diarrhea, Vomiting)

9. What is the date of your pet's most recent rabies vaccination?

Training History

1. Is your pet house-trained?

2. Crate trained?

3. What behaviors does your pet know and reliably perform when asked?

4. Can they perform these behaviors when outside the home or in new areas?

5. What type of rewards does your pet enjoy the most? Check all that apply.

Have you worked with a trainer previously?

Name of company/trainer:

If so, please describe what you learned and how your pet responded to it.

How much time do you have to devote to training daily?

8. Have you ever used any of the following training tools?

Behavior History

How would you rate your pet's general anxiety level?

2. For the questions below, please mark how best describes your dog’s response to these situations. With 1 being calm, loose or wiggly body and 5 being stiff, tail tucked or hackles razed, barking/growling/lunging or attempting to get away

3. Has your pet ever Growled at, snapped at or bitten someone?

If so, please explain what happened before, during and after the event, if a bite happened did it break skin? Did it require medical attention?

Was the incident reported?

4. Has your pet ever growled at, snapped at or bitten another dog?

If so, please explain what happened before, during and after the event, if a bite happened did it break skin? Did it require medical attention?

Was the incident reported?

5. Has your dog every shown signs of resource guarding?

If yes, Please explain the situation:

Behavior Concern

1. What is the primary behavior concern that prompted this visit?

2. How frequently is the primary behavior of concern happening? Check all that apply.

3. How long does it take your pet to return to their normal self after the behavior of concern happens?

4. Are there any additional behavior concerns for your pet?

5. What are your overall goals for your pet.