Behavioral Problems Print & Mail Application

This is a print and mail in application form for Behavior Problems. If you want to use an online version of this form, please click here.   If you need a Private Training Lesson, click here!

Mail to: 1501 S. Center Street  Tacoma, WA 98409

Behavior problems can be difficult, frustrating situations to correct. The information you provide on this form is extremely important in finding a solution to the problems you are experiencing.  The more thorough you are with your answers here, the less time we will need to spend during your training session dealing with questions.  Please attach additional paper if needed. 

GENERAL INFORMATION

Date: _______________________  Referred by:____________________________________________
Name: ____________________________________________________________________________
Address: __________________________________________________________________________
City: ______________________________________    State: ___________  Zip: _________________
Home phone: ______________________________   Work phone: _____________________________
Pet’s Name: ________________________     Breed:  _________________________   Age: _________
Apprx. weight: ______________    Sex: _______  Neutered?    Y      N       Age neutered: ___________ 

Where did you obtain this pet?  Breeder     Friend     Pet shop     Humane Society     Other: __________
Age obtained: _____________  If not the first owner, describe previous home(s), if known: ________
_________________________________________________________________________________

Name, age, sex & breed of other animals in the household: _____________________________________
__________________________________________________________________________________
Veterinarian: ________________________________________________________________________

Availablility

Do you prefer to meet:    [   ]  at our facility?           [   ] in your home?           [  ]  Aggressive Dog Class
Preferred days / time range (this does not guarantee your preferred time slot, but we will do our best to accommodate your needs. See schedule for the date of the next Aggressive Dog Class)  _________________________________________________________________________________

PRINCIPAL COMPLAINT: 

What is the primary problem you are seeking help for?  ____________________________________
_________________________________________________________________________________
_________________________________________________________________________________
How would you describe the severity of this problem?  Mild     Moderate     Severe   Other:  ________
Is euthanasia a possibility if this problem is not solved?  ____________________________________

Describe the problem, beginning with the most recent incident, going back through the last 3 incidents:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

How often has this occurred in the past  a) month: ___  b)  3 months:  ___   c) year:  ___  d)  total:  ___
Has there been a change in frequency or severity?  _________________________________________
What age was your pet when the problem first started?  _____________________________________
Were there any changes in the household when the problem first appeared?  ______________________
________________________________________________________________________________

What has been done so far to try to correct the problem? 
Solution attempted          How long did you try this?                       What was dog’s response?
________________      __________________________           ____________________________ 
________________      __________________________           ____________________________ 
________________      __________________________           ____________________________ 
Which if any of these techniques have had any success?  ____________________________________ 
Which if any of these techniques have made the problem worse? ______________________________ 
What do you think is the reason for your dog’s problem?  ___________________________________ 
_______________________________________________________________________________ 
Have you received advice from anyone about this problem? Y   N    If so, please describe: ___________ 
_______________________________________________________________________________ 
Please list any additional comments regarding the principal problem on another sheet.

ENVIRONMENT/LIFESTYLE

For what purpose was this pet obtained (Companion, protection, show, etc.)? _____________________ 
When is pet fed? ______________________________ By whom? ____________________________ 
Location pet is fed: _________________________________________________________________ 
Favorite treat: ____________     Desire for treat:     Exceptional     Mild        Moderate      Strong   

List household members, ages of children under 18, a short schedule, & how dog gets along with each one.

Amount and frequency of exercise/play: 

Where the dog stay at each of the following times? 

How long is the dog home alone on the average day? ______________________________________
Problems when left alone:     Barks     Destructive     House soiling     Other:___________________
Reaction prior to departure: Unconcerned   Disappointed   Nervous/Anxious  Frantic  Other: ______

TRAINING

Describe any obedience training:    Group lessons     Private training     Other: __________________
At what age? _______________  With which family member(s)?  _____________________________
Success:           Excellent              Good                 Fair                    Failed               Didn’t Complete
What commands work best?  __________________  Which work poorly?______________________
Which family members have most control?  ________________  Least control?  __________________
Describe your dog’s learning ability:  Fast      Slow     Easily distracted     Other:  _________________
Describe your dog’s personality:  _______________________________________________________
Does your dog object to being handled or touched?  Y  N    If so, describe: _______________________

How does your dog react to:
Other dogs on property?  Ignores      Plays      Barks      Attacks     Other: ____________________
Other dogs off property?  Ignores      Plays      Barks      Attacks     Other: ____________________
Loud noises?   No reaction     Startles; recovers quickly     Startles, recovers slowly     Hides
Sudden movements?  No reaction    Startles; recovers quickly    Startles, recovers slowly    Defensive

Has your dog:
Shown aggression towards family members while:                                     Dog’s reaction:

Petting                                                Growl     Bark     Snap     Grab     Glare     Bite, breaking skin
Eating or playing with toy                    Growl     Bark     Snap     Grab     Glare     Bite, breaking skin
Being approached when sleeping        Growl     Bark     Snap     Grab     Glare     Bite, breaking skin
Punishment/discipline                          Growl     Bark     Snap     Grab     Glare     Bite, breaking skin

Shown aggression towards non-family members while:                               Dog’s reaction:

Entering home                                    Growl     Bark     Snap     Grab     Glare     Bite, breaking skin
Entering yard                                      Growl     Bark     Snap     Grab     Glare     Bite, breaking skin

Describe the circumstances of any affirmative answers to the above,  including apprx. dates & severity:
_______________________________________________________________________________
_______________________________________________________________________________
Describe any other situations not previously discussed in which the dog has been aggressive:  _________
_______________________________________________________________________________

During aggressive displays, does your dog exhibit any of the following:
        Cowering?     Ears back?     Tail tucked?     Hackles raised?     Retreating?     Hiding?

Aside from the principle problem, does your dog exhibit any other problem behaviors?    Yes    No
Describe: _______________________________________________________________________

MEDICAL             Please answer the following or have your veterinarian attach a brief medical history.

Has your dog had medical problems?    Ears     Hips    Back     Skin     Allergies    Other __________

Describe: _______________________________________________________________________
What medication is your pet currently taking, and for what reason?  __________________________
_____________________________________________________________________________
How does your dog react to:
                Nail trimming?  _________________________________________________________
                Giving medication?_______________________________________________________
                Bathing?  _____________________________________________________________

I hereby authorize Positive Approach to release any recommendations given as a result of this inquiry to my veterinarian. 

Signature: ___________________________________________       Date: _________________