Behavior Intake Form

Introduction

Please fill out the form below at least two full days prior to our first session. The information in this form will help me come to our first session well prepared to use our time most effectively.

The form starts with general background and progresses to details about your behavior concerns. Please take time to answer every question in as much detail as possible. If a question really does not apply, you can respond “NA”, but please try not to leave answers blank.

Owner Information

Name

Address

Phone

How did you hear about my services?

Dog Information

Name

Sex / Status

Breed(s)

Weight

Date Of Birth

Color(s)

Source

When did this dog join your family? How / why did you chose this dog?

Health Background

Veterinarian

Last Visit

Have you discussed the current issue with your vet? If so, what did they suggest? Describe any health or physical issues your dog has. Describe any prior illnesses and all surgeries with dates. List all currently used medications.

Nutrition

What brand(s) and flavors of food does your dog eat? Describe this dog's feeding schedule (when, where, etc). List any known food allergies or sensitivities. What are your dog's favorite foods / treats? Does your dog protect or guard food / treats from people or other dogs?

Home Environment

Home Type

Neighborhood

List the name, age, and gender of all people in the home. List the name, age, sex, and species/breed of all pets in the home. How does your dog get along with each of their housemates (humans and other pets)? Where is your dog when you have guests over? Do you have a securely fenced yard? Do you use an electronic containment system (e.g., “Invisible Fence”)? How do you exercise your dog? What games do you play with your dog? What are your dog's favorite toys or games? Does your dog protect or guard toys from people or other dogs?

Training History

What level of (or how much) training has this dog had? Who did the training? What kinds of collars have you used with this dog? Flat or Rolled, Nylon or Leather Martingale / Limited Slip Choke / Check Collar Pinch / Prong Collar Remote Electronic (Vibration / Shock) Fence / Barrier Electronic (Vibration / Shock) Bark Electronic (Vibration / Shock) Citronella Spray What kinds of leashes have you used with this dog? Six Foor Or Shorter Leash Long Line (Over 10ft) Retractable Leash

What other training equipment have you used? Head Halter / Face Collar Classic Body Harness No-Pull Harness Baby Gate / Barrier Clicker Calming Cap / Thunder Shirt Muzzle Noise Maker / Shaker Can Spray Bottle Throw Objects Dog Whistle What kinds of rewards do you use for this dog? Audible Marker (click, “yes”) Verbal Praise Touch / Affection Play (tug, fetch, chase, etc) Food / Treats Outings (car rides, etc) What kinds of punishments do you use for this dog? Verbal Reprimand (“no”, “-eh”, “tsst”, etc) Withhold Attention / Leave Room Yank On Leash Grab / Scruff Yell Poke / Hit / Kick “Alpha” Roll Stare At Dog Timeout / Isolation (in crate or other room) List cues / commands that your dog responds to reliably (90% of the time). List any tricks you've taught this dog to do.

Solo Time

How comfortable is your dog in their crate (“NA” if no crate is used)? How much time each day (other than overnight) does your dog spend in a crate? Where does your dog sleep at night? Where is your dog when left alone? What does your dog do as you are about to leave the home? How does your dog act when you return home? Describe any soiling or damage done by your dog when left alone. Does your dog bark, whine, or vocalize excessively when alone?

Confidence / Anxiety

Describe your dog's energy or activity level. Do you think this activity level is normal and appropriate for your dog? Describe your dog's reaction to people coming to the door. Describe your dog's reaction to strangers while on a walk. Describe your dog's reaction to unfamiliar dogs while on a walk. Describe your dog's reaction to thunderstorms or loud noises. Does your dog startle to anything else (e.g., flashes of light, sudden movements, etc)? Check each of the follow that you can readily do with this dog without a fuss: Handle Feet Handle Ears Handle Tail Trim Nails Brush / Groom Put On / Remove Collar Or Harness Take Away Empty Food Bowl Take Away Toys Move From Couch / Furniture Visit A Dog Park Visit Pet Store Or Other Public Place

Human-Directed Aggression

Which of the following best describes the worst bite to a human by this dog? Level 0. This dog has no bite history or aggression towards people. Level 1. Obnoxious or aggressive behavior but no skin-contact by teeth. Level 2. Skin-contact by teeth but no skin-punctures. There may be skin nicks (less than one tenth of an inch deep) and slight bleeding caused by forward or lateral movement of teeth against skin, but no vertical punctures. Level 3. One to four punctures from a single bite with no puncture deeper than half the length of the dog’s canine teeth. There may be lacerations in a single direction, caused by victim pulling hand away or owner pulling the dog away. Level 4. One to four punctures from a single bite with at least one puncture deeper than half the length of the dog’s canine teeth. May also have deep bruising around the wound or lacerations. Level 5. Multiple-bite incident with at least two Level 4 bites or multiple-attack incident with at least one Level 4 bite in each. Level 6. A victim has died as a result of the attack.

If you selected anything other than Level 0 above, please complete the following questions to describe in detail the most severe display of human-directed aggression by this dog:

How many times, excluding play, has there been tooth-to-skin contact from this dog? Who received the worst bite from this dog? Where was your dog? Where was everyone else around your dog? What was everyone doing just before the bite incident? What did your dog do? Describe your dog's body language (posture, ears, tail, face, hair, etc). What was your reaction (or the reaction of the person responsible for the dog)? What was the reaction of the victim / target? Describe your dog's behavior immediately after the incident. Did you attempt to punish or discipline your dog for this incident, and how?

Dog-Directed Aggression

Which of the following best describes the worst bite to another dog by this dog? Level 0. There is air snapping but no contact to the fur or skin (fur should be dry — if the fur is wet, contact was made and the bite is not a Level 0). Level 1. A bite and release with contact to the fur, superficial scratches or removal of fur. No more than 5% of the dog's canine teeth entered the other dog's body or a bite where a dog grips another dog's body and does not release but does not result in any injury. Level 2. A bite and release where 5 to 15% of the dog's canine teeth entered the other dog's body. Level 3. There are lacerations or punctures where 15 to 30% of the dog's canine teeth entered the other dog's body. There may be tearing of the skin from the underlying musculature or subcutaneous pockets. Level 4. There are deep lacerations where 30 to 50% of the dog's canine teeth entered other dog's body or there was a report or evidence of shaking of the head. There are no crushing injuries or serious internal injuries. Level 5. A bite with holding pressure and possibly shaking of the head — external injuries may or may not be present, but serious internal injuries are present. Level 6. A victim dog has died as a result of the attack.

If you selected anything other than Level 0 above, please complete the following questions to describe in detail the most severe display of dog-directed aggression by this dog:

Where was your dog? Who else (dogs and people) were around your dog? What was everyone doing just before the bite incident? What did your dog do? Describe your dog's body language (posture, ears, tail, face, hair, etc). What was your reaction (or that of the person responsible for the dog)? What was the reaction of the victim / target? Describe your dog's behavior immediately after the incident. Did you attempt to punish or discipline your dog for this incident, and how?

Primary Concerns

What is the primary behavior concern that brought you here? How often does this problem behavior occur? Describe in detail the most recent occurrence of this problem. Describe in detail the most severe occurrence of this problem. Describe in detail the first time you noticed this problem. What have you tried so far to address the problem? Are there any other behavior concerns?

Finishing Up

Are you willing to accept praise and critiques of your handling of your dog and cooperate with any recommendations made? Are you willing to make changes to your dog's environment or routine, and accept suggestions regarding equipment changes, managing behaviour, veterinary check ups, etc? Describe any concerns or hesitation you may have to answering “yes” to either of the two previous questions. Please describe your learning style or what modes or methods of feedback would be most helpful for you. List three things you love about your dog.

Please feel free to submit any of the following supplemental materials via email to info@jessemcclure.org, then double check all of your answers for clarity and completeness, then submit this form with the button below.

Videos of your dog's behavior (do not try to elicit problem behavior for a video)
Photos of your dog's living areas
Diagrams of your home, yard, or areas where the problem happens