TORONTO (416) 399-3179      HAMILTON / BURLINGTON (416) 319-2001 

Intake Form

Thank you for reaching out. Please complete the following survey information to allow me to best prepare to assist you and your dog.

Owner Information

Fields marked * are required to proceed with registration. Please make sure these fields are all correctly filled out.

Name:*
Address:*
Primary Phone:*
-
Primary Type:*
Secondary Phone:
-
Secondary Type:
E-mail:*

Please do no include any spaces when entering in your email address or it will be invalid.

Baby Information (If Applicable)

Are you expecting or adopting?
What is your due date?
Do you have children living with you?
Who is your Obgyn? or Adoption agency?
Who can we thank for referring you?
How did you hear about me?*
Please list the names & ages* of all family members/people living with your dog: *
Please list all other pets in the household, including name, age, sex, breed and spay or neuter status if cat or dog:

Dog Information

Dog Name:*
Dog Age: *
Breed:*
Is your dog spayed/neutered?*

Veterinary Information

Veterinarian's Name & Clinic Name (if different)*
Phone:*
-
Date of last vet visit:*
Is your dog up to date on all recommended vaccinations/titers appropriate to his/her age? *
Do I have your permission to share information with your vet (after discussion with you) in the event I feel there is an underlying medical issue? *

Dog History

Where did you get your dog?*
If your got your dog from a rescue, do you know why he/she was surrendered?
If you got your dog from a breeder, where were the puppies kept during their early days?
How old was your dog when you brought him/her home? *
Describe his/her early socialization history (was there lots of opportunity to meet and see new dogs/people/places/sights/sounds?)*

Current Issues

What is the reason for your call? (Please describe in as much detail as possible)*
List and describe the most recent incidents that may have caused you concern (even slightly) in your dog’s past.*
In what period of time did your dog have the most incidents?*

History of Current Issue

How long ago did this behavior start?
Did it start suddenly or come on gradually?
Is it getting worse?
Is there an event that you suspect triggered this behavior? Please describe in detail.
What causes your dog to have an episode? (list any “triggers” that you can think of)
When your dog has an episode how (long does it last, frequently does it occur, long does it take for the reaction to occur)?
How do you usually handle it?

How does your dog behave in the following situations?

When you are leaving/gone from the house?*
When you return?*
With visitors (specify known vs. unknown, children/ages vs. adults)?*
When perceiving unfamiliar objects? when perceiving unfamiliar noises?*
With thunderstorms/fireworks/other loud noises (shouting, etc.)?*

Will your dog freeze, show his teeth, growl, snap, or bite in the following situations?

When you go near or touch his food dish when he is eating? *
If he has a toy, bone or piece of food in his mouth? *
If yes, under what circumstances? *
If he is on his bed, couch or other favourite resting spot? *
If yes, under what circumstances?*
If he is near one person and another person or pet comes over?*
If yes – is he near someone specific?*
If he steals something and you try to get it back?*
If you grab him by the collar?*
When you try to clip nails, check for ticks, or otherwise handle your dog?*
Does your dog ever cower, shake, try to hide or leave, or otherwise act fearful?*
Under what circumstances?*
Does he/she urinate or defecate during the incident? *

How does your dog react to the following types of handling:

Patting head:*
Ear handling/cleaning:*
Rubbing belly:*
Grabbing collar:*
Hugging/kissing:*
Being lifted:*
Nail trimming:*
Brushing:*
Giving pills or liquid medication:*

Training History

Describe any of your dog’s previous training? (Classes, private training, or both)*
List behaviours (including tricks!) you have taught your dog, and how well your dog responds: *
Other than food, what rewards (toy, play, attention, etc.) are most enticing to your dog?*
Do you, or have you ever, used more than a leash and standard buckle collar with this dog?*
How does/did dog respond? *
If yes, please indicate type of equipment used:*

Does your dog respond differently to different family members in the following situations?

When training?*
Please describe:*
When playing?*
Please describe: *
When being reprimanded?*
Please describe: *

Do you, or have you ever, used any of the following punishment techniques with this dog? (Please do not test)

Physical contact (slap, hit, drag, throw, pin down, muzzle grab, etc.) *
What was the dog's reaction?*
Noise (shaker can, siren, etc.) *
What was the dog's reaction? *
Electronic collar?*
What was the dog's reaction? *
Water sprayer or other repellant?*
What was the dog's reaction? *
Verbal reprimand?*
What was the dog's reaction? *
Time out?*
What was the dog's reaction? *
Have their been any major changes recently?*
Please describe: *
Do you have a predictable work schedule?*
How many hours does your dog spend alone each day? *
Do you spend most of your evenings at home?*
Do you travel often/have a cottage or vacation home where you spend a lot of time? *

Areas of the house your dog has access to:

When you are home?*
When you are asleep?*
When you have guests over?*

Play and exercise with your dog:

How often do you walk your dog?*
Is it mostly on leash or off leash?*
Do you use off leash parks?*
What type of stimulation does your dog have in the home? (Check all that apply)

Health and Nutrition

Please list any medical conditions:*
Please list any medications your dog is currently taking:*
Please list any past injuries or surgeries:*
What food do you feed your dog?*
What type of treats do you feed your dog?*
Food allergies:*

Dog and baby safety education

Contact

Toronto
(416) 399-3179
jon@followtheleaderinc.com

Hamilton
(416) 319-2001
danielle@followtheleaderinc.com

CONTACT US