Intake Form

    Basic Info

    Full name: *

    Phone: *

    Email: *

    Dog's name, age, and breed: *

    How were you referred to BlueDog? *

    Household Composition. Please list all people and pets living in the home. If there are children or other dogs please list their age. *

    How old was your dog(s) when you adopted them and where were they adopted from? If applicable please include what state they were originally rescued from before you adopted them. *

    Have there been any significant changes to the dog’s home or surrounding environment recently, such as: construction, move, death, birth or other?
    Please list the changes and describe your dog’s reaction to each. (write n/a if this does not apply) *

    Health Info for the dog with primary behavior problem

    When was the last time your dog had a complete wellness veterinary exam? *

    Does your dog have medical conditions that may impact the training of your dog, such as:
    hearing/sight loss, hip dysplasia, arthritis, other? *

    Does your dog have any food allergies? *

    What medications is your dog on or has been on in the last 2 years? (if any) *

    Please list your dog's food brand and type, along with any supplements they are taking: *

    What is their feeding schedule? *

    Eating behavior: *

    Energy and Exercise

    How would you describe your dog's energy level? *

    Please choose the leash-walking items you use now: *

    (If other please describe)

    Describe your dog’s typical on-leash walk experience: *

    What type of regular exercise does your dog get? *

    (If other please describe)

    Socialization Skills

    People: On a 1-5 scale, with 1 being the worst and 5 being the best, how would you rate your dog’s socialization skills with people? *

    Children: If you have an infant or toddler in the home, please describe:
    1. Your dog’s relationship to the child:
    2. Your child’s relationship to the dog:
    3. What role you play as supervisor, facilitator, or intervener:
    4. Describe any incidents that have occurred that concern you:

    Other dogs: 1-5 scale, with 1 being the worst and 5 being the best, rate your dog’s social skills with other dogs *

    Your Dog's Day

    Describe a typical weekday: *

    Describe a typical weekend: *

    Training History

    Please select all professional training that your dog has previously had: *

    (If other please describe)

    If your dog has had prior training, please list where and the dates of the training.

    Training methods used: *

    (If other please describe)

    Annoyance Problems

    Please describe any annoyance behavior you would like to address with treatment. Such as housetraining, barking, jumping, mounting, marking, or other similar annoyance problems:

    Bite History with Dogs

    Has your dog ever bitten or nipped another DOG? *

    When was the most recent bite to another dog? *

    Did your dog give warning before biting, such as: prolonged growl, short growl, air snaps, body language, or attempt to escape? *

    (If other please describe)

    Did any of the bites result in a veterinary visit due to injuries? *

    If you answered yes to the previous question, please describe the injuries to each animal involved.

    Why do you think your dog bit?

    Dog to people aggression history

    Has your dog ever bitten or nipped another PERSON? *

    When was the most recent bite incident? (Can be approximate.) *

    How would you describe the bite?

    Where did the incident take place?

    Did your dog give warning before biting, such as: prolonged growl, short growl, air snaps, body language, or attempt to escape? *

    (If other please describe)

    Did any of the bites require medical treatment? *

    If you answered yes to the previous question, what type of treatment was necessary?

    (If other please describe)

    Why do you think your dog bit?

    Resource Guarding

    Please check any resources that your dog will attempt to guard from people or dogs: *

    If you checked any of the boxes above, please give a brief description of the behavior and how you addressed the situation.

    Reactivity

    Please rate your dog's intensity of reactivity (barking, growling, lunging, snapping, aggression, etc) in the following scenarios.

    When out for a walk or on leash and you encounter another dog. *

    When out for a walk or on leash and you encounter another person. *

    When out for a walk or on leash and cars pass. *

    When out for a walk or on leash and you encounter a bicyclist, skateboarder, jogger or other fast moving person. *

    In the house when they see something out of the window. (people, cars, dogs, bicycles, etc.) *

    In the house when someone enters your home. *

    In the house and they hear a loud noise or unexpected noise. *

    Please list any other situation that your dog may become reactive in and what your would rate the intensity. (1-10)

    Fearful behavior

    Does your dog display any fear behaviors such as cowering, shaking, avoidance (running or backing away), tail tucking, etc.? If so, please describe when these behaviors occur.
    Examples: loud noises, meeting new people or dogs, new objects, fireworks, etc. *

    Separation Anxiety

    Do you believe your dog has separation anxiety? *

    Describe your dogs behavior when you prepare to leave the house:

    Describe your dogs behavior after you leave:

    If you have a camera in your home, describe what your dog does when you are gone:

    Describe your dogs behavior upon your return:

    Does your dogs separation anxiety cause you or other members of your family any limitations? If yes, please describe.

    On average, how many hours per day is someone with your dog?

    Please check any of the following behaviors that occur when you leave your dog alone.

    (If other please describe)

    Training expectations and goals

    Describe your training goals and expectations: *

    Please read the Private Training Agreement