Separation Anxiety Questionnaire


                        
                            
                        

        
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                                    Client Information
Today’s Date*
                            
                            MM slash DD slash YYYY
                        
                        
Client's Name*
                            
                            
                                                    
                                                    First
                                                
                            
                            
                                                    
                                                    Last
                                                
                            
                        
Home/Cell Phone*
Email*
                            
                        
Dog Information
Dog's Name:*
Date of Birth*
                            
                            MM slash DD slash YYYY
                        
                        
Breed or Breed Mix*
Weight*
Sex:*
			
				
				Female
			
			
				
				Male
			
Spay/Neuter*
			
				
				Yes
			
			
				
				No
			
Overview
Before you acquired your dog, did he/she have a history of separation anxiety or any kind of destructive behaviors?
			
				
				Yes
			
			
				
				No
			
Age of your dog when behavior began:
How long is your dog typically left alone during the day?
How long after you’ve been gone does it take for your dog to begin displaying nuisance behaviors?
Describe your dog’s main sources of exercise and the exercise’s frequency:
Veterinary Information
Date of your dog’s last vet visit:
                            
                            MM slash DD slash YYYY
                        
                        
Is your vet aware of your dog’s behavior?
			
				
				Yes
			
			
				
				No
			
List of all medications your dog is taking or has taken in the last 12 months:
Attempted Solutions
What have you done to try to improve your dog’s behavior or address this situation?
Have you attempted to use any calming sprays? If so, which ones:
Have you attempted to use no-bark collars or bark deterrents of any kind? If so, which ones:
Complaints
Has your dog’s behavior caused family to complain?
Has your dog’s behavior caused neighbors to complain?
If you’re renting, has your landlord expressed concerns about your dog’s behavior?
                    
                    
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                        Environmental Changes
How many times has your dog been rehomed?
Has the dog changed residence recently? If so, please explain when and where the dog came from and moved to:
Have you changed where your dog stays while you’re away recently?
			
				
				Yes
			
			
				
				No
			
Has your or your family’s schedule changed recently?
			
				
				Yes
			
			
				
				No
			
Has construction started within one mile of the home recently?
			
				
				Yes
			
			
				
				No
			
Has a family member joined or left the household recently?
			
				
				Yes
			
			
				
				No
			
Has your dog’s diet changed recently?
			
				
				Yes
			
			
				
				No
			
                    
                    
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                        Symptoms
Has your dog displayed any of these symptoms in your absence? (Check all that apply)
How frequently does your dog display the symptoms in your absence?
Was your dog potty trained before this behavior began?
			
				
				Yes
			
			
				
				No
			
Can your dog look out of any windows while you’re away?
			
				
				Yes
			
			
				
				No
			
What kind of toys does your dog have access to while you’re away?
Is your dog content to be left alone with anyone or is he/she hyper-attached to a single person?
			
				
				Content to be left alone
			
			
				
				Hyper-attached to a single person
			
How quickly are you hoping to have this behavior changed?
Do you have neighbors or family members that could care for your dog in your absence? If not, can you work with a local dog day care to care for your dog while you’re away?
Thank you for taking the time to fill out our registration form. These details will help us better serve you and your dog. We look forward to working with you! 
Please verify the information was entered by you. Thank you.
I understand and agree to the policies at the bottom of this page.*
			
				
				Yes
			
			
				
				No
			
Signature*
By indicating my consent, I am signing this agreement electronically. I agree my electronic signature is the legal equivalent of my manual signature on this Agreement. If I am signing on behalf of another individual, I attest that I have the authority to do so.
To submit your information, please hit send. If you do not receive confirmation the form has been sent, scroll up to make sure all required fields have been entered.

Policies

Paid pre-registration is required to reserve a space in class.
There will be no refunds after class begins.
Please make sure your dog’s vaccinations are up-to-date.
Only healthy dogs may come to in-person classes and training. Owners should keep their dogs at home or reschedule private training in cases of sneezing, coughing, diarrhea or other potentially contagious symptoms.
Owners are expected to maintain and reinforce training outside of the class setting.
Children 8 and over are welcome at in-person group classes as long as they remain with their parents throughout class, and follow trainers’ instructions.
At their discretion, instructors associated with Joyful Dog LLC have a right to refuse admission to or expel a dog/handler from class.

Waiver

I understand that attendance at a dog training class is not without risk to myself, my dog, members of my family or guests who may attend. I agree to release and hold Joyful Dog LLC, its instructors and teaching assistants, the training facility, and their respective officers, directors and employees harmless of any liability arising from this training activity and/or information or consultation provided by Joyful Dog LLC. I expressly assume the risk of damage or injury therefrom.

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