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* 1. Your name:

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* 2. Your dog's name:

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

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

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* 5. Daytime phone number:

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* 6. Evening phone number:

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* 7. Email address:

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

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* 9. Your veterinarian's phone number:

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

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

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* 12. Tell me more about your dog:

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* 13. Where did you get your dog?

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

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

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

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* 17. When did this behavior begin?

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

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

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

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

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

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

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

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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.

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

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

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

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

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

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

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

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* 33. Other information you would like to share:

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