CANINE BEHAVIOR CONSULTATION QUESTIONNAIRE

CANINE BEHAVIOR CONSULTATION QUESTIONNAIRE

Please fill out this questionnaire for each dog.

PET BEHAVIOR QUESTIONNAIRE - PHOENIX DOG TRAINING

Please fill out all areas of this form. The more complete the questionnaire, the better we can assess and help your pet.

  • GENERAL INFORMATION

  • MM slash DD slash YYYY
  • Max. file size: 768 MB.

  • PET INFORMATION (Click the + to add additional Pets/Rows)

  • Pet's NameBreedColorAgeWeightSex 
    Click + For Additional Rows For More Than One Pet
  • Pet's NameAge ObtainedWhere Did You Get This Pet?Breeder, if ApplicableBehavior of Litter-mates? 
    Click + For Additional Rows For More Than One Pet
  • Pet's NameNeutered/Spayed?Age Neutered?Any Change After Neutering? 
    Click + For Additional Rows For More Than One Pet

  • REASON(S) FOR CONSULTATION

  • Pet's NameProblemFrequency (Score Severity 1-10)Intensity (Score Severity 1-10)Duration of Behavior Each Episode (Score Severity 1-10)Onset - When Did Problem Start? 
    Click the + For Additional Rows For More Than One Problem And More Than One Pet

  • INFORMATION ON PRESENTING PROBLEMS

  • Put Pet's Name Then Cause(s)
  • Pet's NameMedicationMg. StrengthFrequency (e.g. once a day, twice a day)How Long on Medication (e.g. days, weeks, months)Outcome (e.g. did the medication help yes/no?If Yes (what % improvement) 
    Click + For Additional Rows For More Than One Medication

  • FAMILY RELATIONSHIPS

  • First NameLast NameSexAge 
    Click + For Additional Rows To Add Addition Family Members
  • Pet's NameSpeciesBreedSex (Spayed/Neutered?)Age ObtainedAge Now 
    Click + For Additional Rows To Add More Pets

  • TRAINING

  • Please Check All That Apply
  • Please Check All That Apply
  • Please Check All That Apply
  • Household MemberSit %Down %Stay %Come %No % 
    Click + To Add Rows For Additional Household Members

  • PUNISHMENT

  • Please Check All That Apply

  • HANDLING

  • Please Check All That Apply

  • MEDICAL SCREEN

  • Please Check All That Apply
  • Please Check All That Apply
  • Please Check All That Apply
  • Please Check All That Apply
  • Please Check All That Apply
  • Please Check All That Apply
  • Pet's NameMedication Name:Dosage:Frequency Given (times per day)Duration Of Medication (how long taken) 
    Click + To Add Addition Rows Of Medications
  • Pet's NameSupplement Name:Dosage:Frequency Given (times per day)Duration Of Supplement (how long taken) 
    Please Click + To Add Additional Rows Of Supplements

  • REINFORCER ASSESSMENT

  • Pet's Name1.2.3.4.5. 
  • Pet's Name1.2.3.4.5. 

  • HOUSE-TRAINING SCREEN (If Your Pet Is Not House-soiling, Skip This Section)

  • DEPARTURE BEHAVIOR SCREEN

  • AGGRESSION SCREEN

  • Situations That Led To Aggression (Answer All That Apply)

  • AGGRESSION TOWARDS PEOPLE (If your Dog Is Not Aggressive Towards People, Skip This Section And Move To The Next)

  • AGGRESSION TOWARDS DOGS (If Your Dog Is Not Aggressive Towards Dogs, Skip This Section And Move To The Next)

  • ANXIETY/PHOBIA/FEAR/ SCREEN

  • Pet's NameTriggerFrequency (Daily, Weekly, Monthly etc.)Intensity Score (1-10) 10 Is Most SevereDuration (How Long Is The Anxiety Attack)Onset - When Did Problem Start? (How Long Ago) 
    Click + To Add Additional Rows For Additional Triggers

  • ADDITIONAL BEHAVIOR PROBLEMS

Save and Continue Later

Please continue to Step 3

Step 3

STEP THREE:  Schedule Your Appointment Date and Time and Pay The $295* Behavior Consultation Fee Here. 

WaitList

PLEASE READ ABOUT MY SERVICES AND PRICES FIRST BEFORE FILLING OUT THE WAIT LIST FORM.

IF YOU ARE EXCITED ABOUT HAVING ME WORK WITH YOU AND WANT TO RETAIN MY SERVICES, THEN PLEASE FILL OUT THE FORM BELOW.

Waiting List

I Specialize in Anxiety, Fears, Phobias, and Aggression. However, I Work with ALL BEHAVIOR PROBLEMS

MM slash DD slash YYYY
HAVE YOU LOOKED AT MY SERVICES AND PRICING? IF NOT, PLEASE REVIEW THEM ON THE PRICES PAGE BEFORE SUBMITTING THIS FORM(Required)