Canine Helpline Intake Form

First Name *

Pronouns

Last Name *

Phone *

Email *

Address

Street Address

City

State

Country

Postal code *

Please list everyone in household including ages

I am interested in the following service:

Animal's Name *

Dog's Age *

Dog's Breed

Dog's weight *

Dog's Sex: *

Spayed/Neutered *

Where did you acquire your dog? *

Are there any other pets in the household? If yes, please specify species/sex/age *

Does your dog have any known physical or medical issues? *

How long have you had your dog? *

Please describe the behavior issue you are experiencing in more detail: *

How often do these issues occur? *

Has your dog ever bitten a person or another animal? If so, please describe the circumstances *

Have there been any recent changes to the animal's schedule or environment (ex. moving to a new home, new animal or person in house, new baby, etc.)? If yes, please explain. *

Describe what you have previously tried in addressing your training goals and how your dog has responded *

Are you considering returning, surrendering or rehoming your dog? *

Is there anything else you would like us to know about your dog? *

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