Behavior Modification Intake Form — Shake On It Dog Training

Please click the button below to access your client agreement. Print and sign prior to our lesson.

If printing is not available please let me know and I will print the form for you.

Client agreement

Please complete the form below

Provide as much detail as possible

Name *

Name

First Name

Last Name

Your age *

Spouse/partner *

Spouse/partner

First Name

Last Name

Names and ages of all children who live with your dog. *

Email Address *

Cell phone number *

Cell phone number

(###)

###

####

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How did you hear about Shake On It Dog Training? *

Your Dog's General Information

Dogs name *

Breed or breed mix *

Dog's age *

Dog's weight *

Gender *

Female

Male

Spayed/Neutered? *

YES

Describe the behavioral issues you are seeking help with. *

How have your tried to solve the issues yourself? *

How long has your dog had these behavioral issues? *

Describe the behaviors or skills you are wanting to build. *

What day/s would you prefer to schedule your consult/training sessions? *

What time/s would you prefer to schedule your consult/training sessions? *

How will your dog receive me as a guest in your home? *

Background and history

Where did you get your dog? If you acquired your dog through a shelter or other circumstance please provide any history or information you received about your dog. *

How long have you had this dog? *

Did you get your dog from a breeder? *

If no, skip to lifestyle section

YES

Who is your breeder?

Was your puppy shipped to you? *

If no, skip to lifestyle section

YES

What age was your puppy shipped? *

Your dog's lifestyle

Please check what type of home you live in. *

HOUSE

APARTMENT

CONDO

TOWN HOME

DUPLEX

RENTING A ROOM IN A HOME

OTHER

What brand of food do you feed your dog? *

Purina, Blue Buffalo, Iams, Science diet, etc.

What type of food do you feed your dog? *

Dry, canned, raw, home-cooked, etc.

Do you use puzzles or toys to feed your dog? *

Where does your dog sleep? *

Is your dog crate trained? *

YES

WORKING ON IT

Does your dog use a dog door? *

YES

Do you have a fenced yard? *

YES

WORKING ON IT

Do you use an electric fence? *

YES

PLANNING ON IT

Describe the daily exercise your dog gets. *

How much time does your dog spend outdoors? *

Your dog's Medical And Health Information

What veterinarian do you use? *

Date of your dog's last wellness visit at your veterinarian? *

List all medical conditions and allergies your dog has. *

List all medications and supplements your dog is taking. *

Training And Behavior

Where has your dog been trained in the past? *

Organization name, trainers' name

Describe the process as to how your dog was trained. *

What was the training like, what methods and tools were used

How successful do you feel the past training was? *

What did you like about your experience with your past trainer or organization? *

What did you dislike about your experience with your past trainer or organization? *

Describe how you discipline your dog. Has it been effective for you? *

Describe how you reward your dog. Has it been effective for you? *

Your Dog Vs. Other Dogs (Skip if you are not seeking help for a dog vs dog related issue)

Describe your dog's past experiences with other dogs that they do not live with. *

Describe exactly what your dog does when he/she sees another dog while on-leash. *

Describe exactly what your dog does when he/she interacts with dogs off-leash. *

Including the dogs he/she lives with, how many fights has your dog had with other dogs? *

Describe ALL the bites your dog has inflicted on another dog, include severity and approximate date. *

Where and how often is your dog exposed to other dogs? *

Excluding dogs he/she lives with

Your Dog Vs. Humans

Describe exactly what your dog does when he/she encounters strangers while out and about. *

Descrbe exactly what your dog does when a stranger tries to pet him/her. *

Describe all the bites your dog has inflicted on a human. Include severity and approximate dates. *