* 1. Your name:

* 2. Your dog's name:

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

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

* 5. Daytime phone number:

* 6. Evening phone number:

* 7. Email address:

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

* 9. Your veterinarian's phone number:

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

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

* 12. Tell me more about your dog:

* 13. Where did you get your dog?

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

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

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

* 17. When did this behavior begin?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

* 32. What days and times work best for your schedule for consultation? You will be contacted with current openings that fit your schedule.

* 33. Other information you would like to share:

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