Dog Behaviour Private Consultation Form Step 1 of 6 16% Section One: Owner InformationName First Last Address Street Address City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home NumberCellular NumberEmail Are you 18 or older? Yes No Have you previously done a consult with one of our trainers?(Required) Yes No If yes, with who? Section Two: Dog's InformationDogs Name Dogs Breed Dogs Age Dog's Sex Is your dog spayed/neutered? Yes No Where did you get your dog? What age was your dog when you adopted it? Section 4: Physical and Medical BackgroundWhat is the name of your veterinarian? Is your dog current on their vaccinations? Yes No Unsure Does your dog have any known medical problems? Is your dog on any medication? Does your dog have any food allergies? Has your dog experienced any of the following conditions? Deafness Ear Infections Allergies Seizures Thyroid Disease Heart Disease Other What was the reason for your last vet visit? Section 5: Consultation ObjectivesWhat would you most like to change about your dog’s behaviour? Name at least three things in order of importance. Add RemoveMajor issue you hope to address in this session Add RemoveIs the dog crate-trained? Yes No What type of exercise does the dog receive? How often? Please describe a typical day in the life of your dog.What is your dog's favourite activity? What is your dog's least favourite activity? Section 6: Feeding and TreatsWhat type of food is your dog being fed? How many times a day is your dog being fed? What is your dog's favourite treat? Second favourite? Section 7: Training and People InteractionHas your dog had any previous training? (If yes, describe who did the training, training methods, familiar cues, etc.)What tricks does your dog know? Does your dog generally respond/listen to you? In the house Outside on walks In the park When people are over Select AllDescribe how you reprimand, correct, or punish your dog for unwanted behaviour.Give an example of the circumstances under which you might administer this reprimand/punishment.Describe how you reward your dog for good behaviour.What type of collar does your dog wear? Nylon Collar Martingale Choke Chain Prong Collar E-collar No Collar Other Who lives in your dog’s household? (i.e. other pets, children, etc.) Who will be responsible for training this dog? Are family members able to handle your dog physically when... Trimming Nails Brushing/Grooming Off-Leash On-Leash Other How does your dog respond to strangers? Happy with a wagging tail Ears up, body stiff, hackles up Jumping Ears back and tail tucked Barking Does your dog urinate when approached by people? Yes No Other How does your dog react to stressful situations? (e.g., with strangers, when left alone, when confined) Wildly active Active Poised and assured Reserved Withdrawn Section 8: LogisticsWhere does the dog sleep? Is the dog allowed on the furniture? Yes No Where is the dog kept when no one is home? For what period of time, on average, is the dog left alone? What percentage of time does the dog spend indoors vs. out? Section 9: Dog-to-dog Interaction and AggressionHas your dog ever caused injury to another dog? Yes No If yes, did either dog require vet care? Please elaborate.Has your dog ever caused injury to a human? Yes No If yes, did they require medical attention? Please elaborate.Has your dog ever displayed aggression or made you feel uncomfortable about what they might do?If yes, what levels of aggression have you experienced with your dog and how many times? Excessive barking Lunging Growling Fixated staring Snap and miss Snaps, hits and lets go (caused bruises and/or scrapes) Single bite (one to four punctures) Bite, grab and shake (causes injury) Death Other Section Ten: Behaviour Session SpecificsWhat prompted you to seek help at this time? How much time and effort are you willing to spend on this issue? Are other members of the household willing to cooperate? Have you considered the following options should these issues not be solvable? Rehoming the dog with a friend, coworker, or relative? Returning the dog to the breeder Surrendering the dog to CHS Humane Euthanasia Is there anything else you’d like to share about your dog and their behaviour? Section 11: Final DetailsWhere would you like the training to take place?(Required) In Home Calgary Humane Society Training Facility What is your availability? Please select possible days. Monday Tuesday Wednesday Thursday Friday Saturday Sunday How did you hear about the classes offered at Calgary Humane Society? Website Social Media Yellow Pages Family/friend referral CHS Adoptions Department CHS PetGear Store Other I have read the following terms and: I agree I disagree Terms Private consultations are by appointment only. No walk-ins, please. Sessions take place at the Calgary Humane Society, located at 4455 - 110 Ave SE Payment must be made in advance of the appointment by Visa, MasterCard, debit, cash or cheque. Fees are non-refundable. In the event that a client is unable to keep an appointment, we require advance notice of two business days. Calgary Humane Society is happy to reschedule at the client's request. Call 403-723-6019 if you are going to be late/need to reschedule. Failure to keep an appointment without two business days advance notice may constitute forfeiture of fees rendered. Email For Internal Use Only