Professional Canine Behaviorists - Comprehensive Training Programs

Professional Canine Behaviorists - Comprehensive Training Programs
Obedience - Agility - Tricks - C.G.C. - Aggression Counseling - Behavior Solutions

What is a Behaviorist?

Pre-Evaluation From

Behavior Questionnaire & Registration Form

STOP!

If we have already discussed your pet's issues and requested that you complete the Behavior History, please scroll down and complete this form. Otherwise, please complete the free Pre-Evaluation form. You may also telephone us at 603-536-4219 to complete the free 15 minute Pre-Evaluation over the phone.

We may determine that your problem doesn't require the detailed history the form below will provide.

**If we have already communicated via email or telephone about your problem, you are in the right place. DO NOT complete the "Pre-Evaluation Form" that is linked in the above paragraph. Our phone or email has communication has already taken care of the pre-evaluation. ***

By completing this detailed history questionnaire you agree to the $35 review and treatment plan completion fee.

We'll reply within 48 hours with a suggestion on the best course of action for your problem.

Your $35 fee includes:

Questionnaire Reviews - Unlimited
Creation of your individualized initial and follow-up treatment plans
Two follow-up emails to clarify questionnaire responses
Printed treatment outline and instruction sheets


Pet Information
Please complete ALL fields! All information that you provide is confidential. It is important to answer carefully as your answers will be used to evaluate your dog's behavior problem. Please answer ALL questions. If a question does not apply to your dog or situation, answer with "N/A."

Pet Name		Nickname
Breed		Birthdate
Weight		Color(s)
Veterinarian Clinic		Vet Phone
Sex	Male Female Spayed/Neutered	If fixed, age done
Age Obtained		Where From?
Cost		Describe the area the litter housed
Describe the behavior of the littermates		Did your puppy appear shy or outgoing?
Is the dog housebroken?	Yes No Sometimes	If you did the housebreaking, please describe your methods in detail
Obedience Graduate?	Yes No Not Taken	If yes, describe in detail the type of training, equiptment used, etc
Date of prior training		Where?
Was it group or private?	Group Pvt	What commands does the dog still perform well?
Where does the dog sleep at night?		Is the dog allowed on the furniture?	Yes No
What brand of food is fed?		Amount of food?
How often?		Who feeds the dog?
Treats given?	Yes No	Table Scraps?	Yes No
Does the dog beg?	Yes No
Last veterinary appointment		Reason for appointment
Briefly describe your pet's health history.		Current and previous medications
Does your dog suffer from any physical condition that might contribute to the problem?

Environmental Information
List the people in the household and their ages. Give status of each person:mom,dad,uncle, etc		Number of children. Sex and age of each
Other pets		What pets have you previously owned?
If your previous pets had behavior problems, what were those problems?		Please describe the dog's daily exercise routine
Is your yard fenced?	Yes No	Describe the dog's exercise area
How Iong is the dog exercised daily?	15 M. 45 M. 1 Hr. 2 Hr.	What tyoes of play does your dog enjoy most?
Describe your dog's reaction to be left alone
Describe your dog's behavior when you return home
Do you use a crate?	Yes No
How many hours a day does your dog spend in a crate?

What toys does the dog have?	Kong Nylabone Rope/Tug Rawhides Stuffed/Plush Tennis Ball Describe other toys

Behavior Information
Pet's age when the problem was first noticed		Describe in detail the events of the first instance
What seems to trigger this problem?
What was your response to this behavior?		Describe any punishments you have administered. Be honest and detailed.
How often does this problem occur?		Has there been a recent change in the frequency or severity?	Yes No
Have there been any changes in the household that might explain the appearance of the problem? Explain.		Besides the punishments described above, what else have you done to try and correct this problem?
Have you seen other trainers about this problem? What did they suggest?
Have you thought of giving up, or having this pet put to sleep?	Yes No	Why do you think this behavior is occuring?
Does your dog show signs of fear prior to becoming aggressive?	Yes No	Explain what you observe as fear
More aggressive towards males or females? Please specify if your speaking of dogs or humans.
Is there anyone the dog is never aggressive towards?
What is your goal with this training?		Provide us with any other details that might be helpful

Aggression Profile

Instance	Yes	No	Does not apply
Bitten anyone?
Killed an animal?
Growls or nips when:
Reaching for food bowl
Reaching for bone or toy
Giving verbal reprimand
Moved while sleeping
Moved off the furniture or bed
Held back by collar when trying to run
While being petted or hugged
Lifting the dog
Clipping nails
Brushing
When visitors enter yard
At approaching strangers
When stared at
At a knock on the door
In the car when strangers approach
Around children
At the veterinarian
At bicycles
During rough play with humans
Other: Please describe

Customer Information
First Name
Last Name
Address
City
State
Zip
Phone
Email

Behavior Appointment / Schedule Date Private sessions are scheduled between 9:30 am and 5:00 pm, M-F We service the Littleton, NH - St. Johnsbury, VT area on Mondays.
	Time
Alternate Day and Time
	Time
Date Comments


Contract & Payment- This is an encrypted, secure form
*You must agree to our Training Contract [view] and Charge Policy as seen below, to complete your registration. I Agree I Disagree

Your credit card is required below to confirm your training reservation. All offerings are charged a non-refundable $50 deposit. If you cancel within 48 hours of your scheduled appointment time, you may apply the deposit to another class. Your deposit is non-transferrable. For Private Class Packages, at the end of the first class you may choose to continue training and pay or not continue training and be under no obligation to pay, at which point we will refund your deposit, minus any applicable travel fees. We understand that the instructor-student relationship, pet-instructor relationship, or training methods may not be compatible in all cases, therefore you are given one class to "feel out" the next four weeks before you pay.The guaranty applies only to private offerings. We do not issues refunds for any reason for group classes or behavior consultations.

CardHolder:
Card Number:	Exp. Date ( mm/yyyy ) CVV2: (last 3 numbers on card back)

How did you hear about us? Please be specific.
Comments: