Separation Anxiety Intake

Client Name

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Location (City, State)

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Phone number

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Dog's Name

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Dog's Age

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Sex

Male

Female

Dog's Breed

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Where was dog acquired? (Shelter/Breeder/Other)

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How long has dog been in your household?

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How often is your dog being left alone currently?

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Have you done any training to address Sep Anx?

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How long would you like to leave your dog alone?

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Is your dog currently on anti-anxiety medication?

Yes

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For separation anxiety training to work, you really would need to find a way to stop leaving your dog. How do you feel about that?

That's unrealistic

Might be doable

I'm already doing that. My dog is never left alone.

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