Client Information Sheet – URGENT Use this form to initially book a consultation Step 1 of 6 0% About youName* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country How would you rate your level of fitness?*click to selectAthleteFitAverageNot fitInjuredWhat age group do you fall into?*Click to selectUnder 1818 - 2222 - 3535 - 5050 plusDo you have any health problems, please list or write none if none*What is the date your first consult is booked for?*We have sent this to you in an emailDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What time is your consult booked for?* : HH MM AM PM Your dogs basic detailsYour Dogs Name*What breed/s is your dog?*What age will your dog be at the consultation*How old was your dog when you got him or her?*Is your dog desexed or entire*Does your dog have any allergies? If so, please listDoes your dog have any injuries? If so, please listPlease upload a recent photo of your dog for our records Is your dog on any treatments, medications etc? Please list if so.When was your dogs last Vet visit and what was that for?*How would you describe your relationship with your dog?*Describe your dogs personality*What is your dogs favourite activity?*Your dog and peopleIn the below questions, please list the value your dog has for people. 0 being fearful or aggressive, 5 being relaxed around them and 10 being highly excited by them.YouAdults your dog knowsAdults your dog does not knowChildren your dog knowsChildren your dog does not knowAre there things that people can do that cause your dog to miss behave?Perhaps your brother arriving at your house, or a stranger looking in your dogs eyes.Other DogsIn the below questions, please list the value your dog has for dogs. 0 being fearful or aggressive, 5 being relaxed around them and 10 being highly excited by them.Adult dogs your dog knowsAdult dogs your dog does not knowPups dogs your dog knowsPups dogs your dog does not knowAre there things that other dogs can do that cause your dog to miss behave?Perhaps a dog at the park may stop your dog from coming when called, or a strange dog barking at your dog causes your dog to react.Are there certain dog breeds or types that your dog does not like?Various things in your lifeIn the below questions, please list the value your dog has for the items or situations. 0 being fearful or aggressive, 5 being relaxed around them and 10 being highly excited by them.Cars, bikes, LawnmowersOther animals such as birds, mice, possums, cats etcNoises such as fireworks, thunder, traffic, shouting A little more detail about your dogHow would you rate your dogs fitness on a scale of 0 -10, 0 being unfit to 10 being super athleteHave you ever considered that your dogs fitness maybe contributing to the issues your having?Do you do any type of fitness training with your dog?What diet do you feed your dog?*Do you use any supplements? If so please list.*Do you give your dog bones?*Can you take a bone from your dog whilst he or she is eating it?*Do you use food treats when training your dog? if so what do you use?Now lets find out what motivates your dogWhat do you use to reward your dog in training?*How does your dog react to be rewarded this way?*Do you play tug with your dog?*YesNoDo you throw a ball for your dog?*YesNoList in order from highest to lowest the value your dog has for food, tug or a ball.*Example FOOD, TUG, BALL would mean food highest, tug middle and ball leastDescribe what problems you have had in training*Does your dog lack interest in the reward? Is he or she more interested in other things? What distracts your dog the most in training?*Some history about your dogHas your dog ever bitten or growled at you?*If yes please describe the incidentHas your dog ever bitten or growled at someone else?*If yes please describe the incidentHas your dog ever attacked another dog?*If yes please describe the incidentHas your dog ever been attacked by another dog?*If yes please describe the incidentWhat do you like most about your dog?*What do you like least about your dog?* Your dogs living arrangementsIs your dog allowed inside your home?*Is your dog crate trained?*Describe how your dog behaves when you come home?*Describe how your dog behaves when a visitor arrives*How do you handle the above situation?*How often does your dog have access to you when you are at home?*Do you take your dog with you when you go out? If yes how much?*Is your dog destructive? does he or she dig, chew, bark or escape?*If you have other dogs at home, please list what dogs you have, their sexes, ages and what relationship they have with the dog your bringing to see us. Training levelWould you call your dog obedient?*YesNoWhich one best descibes your dogs recall?*Select the most accurate one.Will come when he or she feels like itWhen he or she is in the backyard onlyMy dog will come every time I call him or her, in all circumstancesMy dog wont recall anywhere, any time.My dog pulls on the leash*complete this sentenceneverhe or she anticipates somethingall the timewhen we start the walkwhen he or she sees a dog or personhe or she is frightenedhe or she is excitedDescribe how much exercise your dog would get per week and what that exercise includes*Do you think this is enough exercise?*YesNoHow would you describe yourself as a trainer for your dog*Why are you coming to see us?List the main reason/s you have come to see Steve*If you could change one thing about your dog, what would that be?*What training methods or systems are you interested in learning more about?* Reward Based Training Positive only training Clicker Training Training in drive Motivational Training Leadership skills / Pack leader Training Balanced Training Training that involves corrections Remote Collar Training Other Are there any training systems, methods or tools that you wish to avoid? Please list and explain why* Just finally...What are your long term goals with this dog* Obedient Pet Competition Obedience Agility Flyball IPO / Schutzhund Other Dog Sport Scent work or tracking Other Do you think you can achieve your goals?*Yes!No?PossiblyI don't knowDo you have any dog training qualifications?*YesNoDo you help other people train their dogs?*Please enter yes or no. If yes please explain in what capacityWhat do you hope to gain from your consultation with Steve*How much time per day can you allocate to this program*Other than this program, what else will your dog be doing?*Are your goals for this consult your highest priority with your dog?*In other words would you cease another or all other activities to help this one?How did you hear about us?*select as many as you like Referred by a friend Referred by a vet Referred by a trainer or behaviourist Sent by Council Our websites Facebook YouTube Forum Web search Seminar or Workshop Other Feel free to add any other information you think might be relevant here.PhoneThis field is for validation purposes and should be left unchanged. 2016-02-29 steve courtney
Steve Courtney Dog Trainer Dog Trainer & Behaviorist Australia