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Behavioral Therapy Intake
1.
Owner's Name:
2.
Dog's Name:
3.
Please submit a photo of your dog:
Choose File
No file chosen
4.
Breed:
5.
Age:
6.
Sex:
Male
Female
7.
Which rescue organization referred us?
8.
How long have you owned them?
Less than 3 months
Less than 1 year (4-12 Months)
1-2 years
more than 2 years
9.
Has your dog bitten another dog?
Yes
No
10.
If yes, what is the worst result that has occurred?
snap
contact with zero damage
nip with bruising
punctures
gash or tear
fatality or mutulation
None of the above
11.
Has your dog bitten a person?
Yes
No
12.
If yes, what is the worst result that has occurred?
snap
contact with zero damage
nip with bruising
punctures
gash or tear
fatality or mutulation
None of the above
13.
How long has the reactivity or aggression been going on?
Single incident
One month
Six months
One year
Two years or more
Other (please specify)
14.
Does their reactivity behavior usually occur in conjunction with:
being behind a fence
being on leash
being in a car
In home
Other (please specify)
None of the above
15.
What behaviors occur when your dog sees another dog while walking?
tail and body stiffen
fixation
wagging trail and whining
barking and lunging
growling
cowering
fleeing
trembling
Other (please specify)
None of the above
16.
Number of Dog friends?
many
1 or 2
none
17.
Warms up to a new dog:
Quickly
Slowly
Upon first meeting
Over many meetings
Never
18.
Prefers? (dogs)
Males
Females
Adult
Small
Big
Other (please specify)
None of the above
19.
Prefers? (humans)
Males
Females
Children
None of the above
20.
Is the reactive behavior:
Less likely after exercise
Less likely after lots of dog contact
Other (please specify)
None of the above
21.
Did any of the incidents have occurred protecting:
Toys or other objects
Food
Treats or Chews
Favorite spot
Favorite person
None of the above
22.
Does the reactivity or aggression occur during play?
Yes
No
23.
Did the incidents include any of the following:
Humping
Staring down
Stalking
None of the above
24.
Does it appear that your dog targets only particular types of dogs?
Yes
No
25.
Is the size of the human or dog a factor?
Yes
No
26.
How much training if any has your dog received?
Puppy socialization
Basic obedience
Reactivity training from another trainer
Protection
Other (please specify)
None of the above
27.
How much exercise does your dog currently get a day
10 minutes
30 minutes
An hour or more
No exercise;
Very little exercise due to lifestyle limitation
Other (please specify)
Current Progress,
0 of 27 answered
