Safe at Home questionnaire

Today's Date*

What service or program are you interested in?*

Names and relationship of other adult household members*

Any children under 18 living in the home? Names & ages*

Occupation*

Dog's name*

Dog's age*

Breed or breed mix*

Dog's gender*

Male

Female

Spayed or neutered*

Yes

No

How long have you had this dog?*

Are there other dogs in the home?*

yes

no

If yes, list names, ages, breeds, and gender

Are there other animals in the home?*

yes

no

If yes, what kind of animals?

How did you learn of us?*

Name of Veterinarian*

Do we have your permission to discuss your case with him/ her?*

yes

no

Where did you get your dog? At what age?*

If adoption or rescue dog, do you have any background information on the dog?*

If you took classes or previously worked with a private trainer, where did you take classes or who was your trainer?*

Date of last vet visit*

Any current medical problems?*

Currently on any medication?*

Is your dog sensitive to any sounds? Describe*

How long is your dog being left home alone currently?*

Can you adjust your schedule so that your dog will not have to be left alone during training for awhile?*

Yes

No

Maybe

Have you done any previous training to address your dog's separation anxiety?*

Yes

No

If you answered yes to the previous question, please explain what you have tried

Have you discussed your dog's separation anxiety with your veterinarian?*

Yes

No

How long would you like to be able to leave your dog home alone in the future?*

If you have any additional comments in regards to your dog's future alone time, please enter those here.

Please let us know days and time frames you are available for us to schedule this call. *