First Name
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Last Name
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Phone Number
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Email
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City
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Date of your first appointment with us
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How many dogs do you have
1
2
3
4
5+
Dog 1’s name
Age
Breed
Dog 2’s name
Age
Breed
Dog 3’s name
Age
Breed
Dog 4’s name
Age
Breed
Add details for additional dogs in the Other Comments box below
Anything about your dog’s backstory related to its SA?
How long has your dog(s) been experiencing SA
When did you first notice your dog’s signs of separation anxiety
How long before or after you leave does your dog’s separation anxiety symptoms start
How long does the Separation Anxiety last (10 min after we leave, the whole time, 30 min after we return home)
Did any changes to your lifestyle occur at the same time or before the SA started (Moving to a new home, loss of pet or family member, new baby, new dog, new cat, etc)
Have you noticed certain activities are related to your dog’s SA symptoms (putting on work clothes, grabbing your purse, picking up keys, etc)
Do you kennel your dog(s)
How much exercise does your dog get on a daily basis
Is your dog allowed on the furniture
Does your dog have a dog bed
Does your dog use the dog bed
Do you have an electric fence
Do you use a bark collar
Do you use a prong / pinch collar (If yes, when did you start, how long and how often is it worn)
Do you use an e or shock collar (If yes, how long and how often)
Do you use a collar or harness
How often is your dog left alone
How LONG is your dog left alone
Do you have a security system or auto door locks that make noises when activated
Have you ever used dog daycare
Is your dog on any medications or supplements
Does your dog have any health / medical issues
What are your ultimate goals for your dog
What steps have you taken so far to address the separation anxiety
Is there anything else about your dog or its Separation Anxiety we should know about?
Other Comments
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