Your name:

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* 1. Your name:

Your dog's name:

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* 2. Your dog's name:

How were you referred to Animal Behavior Insights?

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* 3. How were you referred to Animal Behavior Insights?

Street address, City, State and Zip Code

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* 4. Street address, City, State and Zip Code

Daytime phone number:

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* 5. Daytime phone number:

Evening phone number:

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* 6. Evening phone number:

Email address:

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* 7. Email address:

Your veterinarian's name and practice name:

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* 8. Your veterinarian's name and practice name:

Your veterinarian's phone number:

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* 9. Your veterinarian's phone number:

Your veterinarian's email or FAX number for receiving case summaries:

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* 10. Your veterinarian's email or FAX number for receiving case summaries:

What medical tests or exams have taken place since behavioral symptoms began?

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* 11. What medical tests or exams have taken place since behavioral symptoms began?

Tell me more about your dog:

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* 12. Tell me more about your dog:

Where did you get your dog?

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* 13. Where did you get your dog?

How long ago did they join your family?

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* 14. How long ago did they join your family?

What was your dog like as a puppy?

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* 15. What was your dog like as a puppy?

Describe the main behavioral problem you are seeking help with:

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* 16. Describe the main behavioral problem you are seeking help with:

When did this behavior begin?

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* 17. When did this behavior begin?

What have you tried to do to change this behavior problem so far?

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* 18. What have you tried to do to change this behavior problem so far?

What other behavioral problems does your dog display? (Check all that apply)

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* 19. What other behavioral problems does your dog display? (Check all that apply)

Please describe any behavioral problem that your dog is experiencing not listed above.

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* 20. Please describe any behavioral problem that your dog is experiencing not listed above.

For any behavior checked above, please describe any relevant details:

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* 21. For any behavior checked above, please describe any relevant details:

Has your dog bitten a person? If so, how badly? Please describe.

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* 22. Has your dog bitten a person? If so, how badly? Please describe.

Please list the human members of your family by name and age (if under 18).

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* 23. Please list the human members of your family by name and age (if under 18).

Please list the animal members of your home by name, age, sex and species/breed.

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* 24. Please list the animal members of your home by name, age, sex and species/breed.

What training has your dog received? Please list cues that they know and include those behaviors they struggle with learning.

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* 25. What training has your dog received? Please list cues that they know and include those behaviors they struggle with learning.

Does your dog have experience with any of the following cues? Check all that apply:

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* 26. Does your dog have experience with any of the following cues? Check all that apply:

What does your dog eat? Please list type of food, amount and schedule.

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* 27. What does your dog eat? Please list type of food, amount and schedule.

What exercise does your dog receive? Think about play, walks etc.

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* 28. What exercise does your dog receive? Think about play, walks etc.

How many minutes per day are you able to spend working with your dog to improve their behavior?

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* 29. How many minutes per day are you able to spend working with your dog to improve their behavior?

How serious a problem is this behavior for you and your family?

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* 30. How serious a problem is this behavior for you and your family?

What kind of consultation are you looking for?

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* 31. What kind of consultation are you looking for?

Which of the following current openings might work for your schedule? 

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* 32. Which of the following current openings might work for your schedule? 

Other information you would like to share:

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* 33. Other information you would like to share:

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