At-Risk Assessment
Emma Kesler, CDBC, CPDT-KA
Email *
Your Name *
Phone Number *
What time zone are you in? (Example: CST, PST) *
Address: Street *
Address: City *
Address: State / Province *
Address: Zip Code / Postal Code *
List all current household members and each person's relation to you (example: "Husband"). Please also indicate ages for anyone under 18. *
Please list frequent visitors to the house, and each person's relation to you (example: "Grandchild"). Please also indicate ages for anyone under 18. *
Are there any other pets in the house? *
Dog's Name *
Dog's Breed *
What got you interested in this breed? *
How old was your puppy/dog when you got him or her? *
Please describe any background information that you are aware of about your dog before you acquired him/her. *
Dog's Date of Birth *
MM
/
DD
/
YYYY
Is there anything else about the story of this dog entering your life that you'd like to share, or the dog's first days with you?
Dog's CURRENT age *
Did you grow up with dogs? If yes, tell me about them. Breed, temperament, etc. *
Have you owned dogs as an adult? If yes, please tell me about them. Breed, temperament, etc. *
What does your dog currently eat? Please be detailed and list food brand, and any sorts of chews/treats. Also list if your dog has ANY (no matter how minor) digestive issues. *
How often is your dog left at home alone? *
Does your dog have, or has he/she ever had any health concerns? Please be detailed. *
Do you have a yard? (It is ok if you don't!) *
Please check any and all concerns that apply: *
Required
Has your dog bitten a person in an aggressive manner? Please describe any incidents in great detail.
Has your dog bitten another dog in an aggressive manner? Please describe any incidents in great detail.
Tell me more about your concerns, and how those concerns fit into your family lifestyle. ALL concerns are important and valid, no matter how small. Everyone who has filled out this form to date has been a very kind, well-meaning person and I do not expect you to be any different. There is no judgement here. I want to help you. *
Do you own an iPad or iPhone? (it is ok if you don't) *
Preferred time of day to meet?
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy