If you have already paid your fees, please complete this form and email it prior to your consultation with the behaviorist. If you have not yet done so click here. For items you may not know or do not apply please put N/A. All items are vital to help properly assess your situation. Each appointment is geared to dealing with one primary problem. You should book an extended appointment if you want to discuss additional topics. The printable form is here or you can return to the index now.

Today's Date: Type of Consultation Desired: Phone Email Appointment How did you find our site? Referral Another Website Link Search Engine Chat Room Printed Material Email Other

Although we cannot always guarantee your choice, please give us your preferred day and time slot for appointments You will be emailed an appointment date and time which you must confirm. This does not apply to email consultations.

Monday Tuesday Wednesday Thursday Friday Saturday Not Applicable Preferred Day Morning Early Afternoon Mid Afternoon Late Afternoon Early Evening Evening Not Applicable Preferred Time Slot

This form is for domestic animal and bird consultations only. Zoos may visit this form. Please note: We do not conduct aggression cases over the phone or via email.

HUMAN INFORMATION

Name of owner working on this problem: email address@host:
Mailing address (Street or PO Box): City: State:
Country: Postal(Zip)Code:
Your Time Zone Pacific Central Mountain Eastern Other Daytime Phone: Evening Phone:
Emergency Contact: Emergency Phone:

List other household members/relation/age/feeling about pet and the problem:

What are the former or current occupations of adult members of the household? (This IS important):

Have you ever attended a training program or behavior seminar before? Yes No
If yes, did you complete the program? Yes No Certificate awarded? Yes No
Who conducted the program or seminar?

PROBLEM BEHAVIOR(S) :
1) Briefly describe problem 2) the age when first observed 3) how long the problem has been in existence 4) where it occurs
5) what particular situation it occurs in 6) frequency 7) how you have attempted to correct it.

ENVIRONMENT INFORMATION

Please list the other animals in the same household:
Name Breed/Species Age/Sex*/Compatibility with this pet
* (Please note neutered animals with an N next to sex listed)

The living environment is a: House Duplex Apartment Townhome/Condo Retirement Ranch Other Does the residence have a private yard or garden? Yes No

ANIMAL INFORMATION

Pet Call Name: Sex: M F Breed/Species: Neutered? Yes No
If yes, at what age? Current Pet Age: Approximate Birthday:

List any of the animal's health or physical problems:

Is this animal on medication? Yes No
If yes, What? & Why?

Was this pet ever seriously injured Yes No or ill? Yes No
If so, please explain:
Is your pet current on all required immunizations? Yes No Does this animal have a valid license? Yes No
What age was the pet first vaccinated? Veterinarian: Name
Clinic City, State Phone (w/AC)

Age this pet was obtained: From where? Shelter or rescue agency Breeder Pet Store Friend Found Other
Approximate price paid? Age taken from mother?
Litter behavior/birth order? How long have you had this animal?
Do you intend to show or breed this animal? Yes No If yes, explain:

Is this pet allowed inside the house? Yes No Where?

Is your pet kept outside the house? Yes No Where?
If your pet was more mannerly would you allow more inside privileges? Yes No
Where does this pet sleep? Where does the pet eat?
Does this pet have their own food bowl? Yes No Who feeds the pet?
Brand name of pet food: Canned Kibble Semi Moist Natural or Raw Diet Other Fed 1X Daily Fed 2X Daily Fed 3X Daily Free Feeds Other
What type of supplements does your pet receive?
Is your pet currently restrained? Yes No
How? Not restrained Tether or chain Runner Crate Own room Kennel Run Yard Other Length per day? Not restrained or confined Max of 2 hours Max of 4 hours Max of 6 hours Max of 8 hours Longer than 8 hours All the time
How often is your pet exercised or played with per week? Multiple times per day At least twice daily Daily Several times a week Three times a week Twice a week Once a week None Other
What types of games are played? How many toys does your pet have? None 2-3 <6 <12 >12
Has this pet ever received any formal training? Yes No At what age?
Trainer's Name: Type of Training: Manners + come, sit, etc., Puppy preschool Novice obedience Advance obedience Agility Scent Show/Confirmation Rescue Tricks Other More than one on this list City/State:
Did you complete the training program with this pet? Yes No Methods: choke chain or pinch clicker training positive reinforcement alternative therapy other
How have you reinforced good behaviors?
How have you reprimanded for bad behaviors?
Pet's reaction to these actions?:
Has your pet growled, nipped or bitten anyone? Yes No How many times has this occurred?
Please detail ALL incidents & explain the circumstances:
How long ago was the first time? How long ago was the last incident?
In stress situations (new situation, strangers, visitors, left alone, confinement, etc.,) how does this pet react:
Would you describe your pet as: Wildly active Active Confident, Assured Reserved Withdrawn Stiff, Lethargic Fearful, Unsure