Private Day Training Intake Form Private Day Training Services Intake Form: Client & Dog Information Guardian's Name: * Referred By: Cell Phone: Home Phone: Work Phone: Email: * Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Dog's Name/ID: Breed, Approximate Age, and Sex: Dog's Name/ID: Breed, Approximate Age, and Sex: Dog Behavior What are your two biggest challenges with your dog's behavior? * What is your response to the behavior when it happens? * Does the challenging behavior happen with yourself or other members of the household? * List all members in the household. * Have you worked with a trainer previously for this issue? * Yes No What did the trainer recommend? * Have you spoken to your veterinarian about your dog’s behavior? * Yes No What did your vet recommend? * Is your dog on any medications? * Yes No Please list your dog's medications: * Do you have fencing? * PhysicalNo FencingInvisible shock fence Describe your dog's daily exercise routine. Include duration and any information on enrichment (mental stimulation, problem solving games, social interactions with other dogs, opportunities to engage in species specific behavior). * How much time can you dedicate to practicing the training each day? * How would you best describe your dog? * Hyperactive and impulsive Bonded to me Confident Fearful of new people Fearful of new dogs Loves food treats Loves to play Loves toys Perpetual motion machine Picky eater Reserved Sensitive Stays focused Tires easily OtherOther What does your dog do when they meet a new person? * Acts friendly Barks Cautiously approaches Growls Hides Lunges Reserved Seems stressed Stares Wants to play Wiggles Has your dog bitten or tried to bite another dog or person? * Yes No Please explain the context of the bite. Describe injuries if sustained. * How long have the behavior challenges been occurring? * Do you or have you ever used physical discipline with your dog? E.g alpha rolling, pinning, hitting, kicking, pinching, pushing). * Yes No Please describe the context of the physical discipline. * What equipment do you use with your dog? * Body harness Long line Flat collar Short leash Muzzle Slip lead Halti or head collar Please check the type of training and methods that have been used with your dog. * Group class Private instructor DIY Clicker training Choke-pinch or prong collar Remote e-collar or shock collar Positive reinforcement training/treats Dominance based or pack leader type training Please add any additional information you’d like us to have. Emergency & Health Information Emergency Contact Name: * Emergency Contact Phone(s): * Vet Office/Vet's Name: * Vet Phone: Please List Current Medication(s) and Reason(s) for them: Visual Code Important Medical History Notes: Visual Code May we share your training & behavior report with your veterinarian? * Yes No Media Consent I acknowledge that images or videos of myself, my child (if applicable), and my dog may be used by [Your Business Name] for social media, marketing, and promotional purposes. These materials may be used in various formats, including online platforms, print materials, and advertisements. I understand that I will not receive compensation for the use of these images or videos and waive any rights to inspect or approve the final materials. This consent is given voluntarily and may be revoked in writing at any time. * Agree Disagree Home Information Other Professionals, Service Providers, or Visitors Expected During Training/Walking Hours: Others Who Hold Keys to the Home: Days Okay For Training/Walking Visits: Mon Tue Wed Thur Fri Sat Sun Times Okay for Training/Walking Visits: * Example: 8:00am - 11:00am or 1:00pm - 3:00pm Description of Services - to be filled out by Amy Terceira Description of Services: Visual Code Rate: Total Due: Payment Information and Agreement - to be filled out by Amy Terceira Form of Payment: Bank Transfer Paid in Full: Yes Payment Date: Submit If you are human, leave this field blank.
