New Client Intake Form

Phone Number

(402) 768-1004

Email Address

[email protected]

Owner / Head Trainer

Ryne Dlouhy

Intake Form

Submit the Intake Form online, or download a copy to fill out by hand, then scan and email back to [email protected]

Owner’s Name

Address

City

State

Zip Code

Phone Number

Email Address

Occupation

Type of Residence

How did you hear about us?

Dog’s Name

Breed/Mix

D.O.B. or Age

Weight

Color/unique markings

Sex

Male Female

Spay/Neuter Status

Intact Neutered Spayed

If spayed/neutered, at what age?

If spayed/neutered due to a behavioral problem, explain.

Fenced yard?

Yes No

Invisible Fence

Yes No

Where did you obtain your dog?

How long have you had your dog?

Were there previous owners?

If yes, why was the dog given up?

Type of ID

Why did you get your dog? Please check all that apply

Have you owned other dogs in the past?

Yes No

If yes, what what breed(s)?

List any physical/breed characteristics that contributed to your choice for your current dog:

Veterinarian’s Name

City

Month/Year of last visit

Date last vaccinated:

Vaccine(s)

Current health problems/Medications

Past medical conditions/Treatment

Does your dog have any allergies, including food allergies?

Is your dog easily handled by vet staff?

Yes No

Has he/she ever had to be muzzled?

Yes No

Is your dog on heartworm preventative? If so, what brand?

Is your dog on flea and/or tick preventative? If so, what brand?

May we contact and discuss health and behavioral issues with your veterinarian?

Yes No

If yes, please initial here

What type of food do you feed? (e.g., raw, dry kibble, canned)

How often?

How much?

At approximately what times?

Does your dog finish all food at meals?

Yes No

If not, how long is the food left down?

Does your dog receive other treats/chewies?

Yes No

Frequency/Type

Please list 3 of your dog’s favorite foods/treats:

Has your dog ever become possessive of his food or a treat?

Yes No

Please describe in as much detail as possible:

Is your dog reliably housetrained?

Yes Mostly (infrequent accidents) No

Is your dog crate trained?

Yes No

Paper/pad trained?

Yes No

Litter box trained?

Yes No

Do you have a dog door?

Yes No

If not, how many times daily do you let your dog out (or take him on walks) to eliminate when you are at home?

How many times per day does your dog normally defecate?

What type of exercise does your dog get? (If not receiving any exercise at this time, note “none” and the reason.)

How long does the exercise last/how often is it provided? (For example, “a 15-minute walk three times daily,” or “plays with neighbor’s dog for an hour once a week.”) _

Who is normally responsible for exercising your dog?

If walks are provided, what type of collar and leash is being used? (Collar examples: “regular buckle collar,” “head halter,” “body harness,” “pinch/prong collar,” “choke chain.” Leash examples: “6-foot nylon leash,” “retractable leash.”)

Does your dog ever become reactive toward other dogs or people on walks?

Yes No

If so, please describe:

List all people, including yourself, who live in your household (Include Name, Gender, Age of Children, Relationship to you)

Who will be responsible for practicing training exercises with the dog?

Does your dog “belong to” a particular household member (e.g., son) or everyone?

Do any household members dislike the dog, and if so, why?

Are any household members frightened of the dog, and if so, why?

Is the dog frightened of any household members, and if so, why?

Where is your dog kept when you are not at home? Please check all that apply

If ‘Indoors confined’ or ‘Other,’ please explain.

When you are at home, is your dog allowed in the house?

Yes No

If your dog is not allowed indoors at all, why not? Please check all that apply

If ‘Destructive’ or ‘Other,’ please explain.

If your dog is an outdoor dog, would you like him to eventually be able to be indoors?

Yes No

If indoors, is your dog ever confined (crated, penned) while you are home?

Yes No

How?

“If so, how long is your dog confined on an average day, and why?

Where does your dog sleep at night?

In a crate?

Yes No

How many hours per day is your pet without human companionship?

Do you have other pets?

Yes No

If so, what kind, breed, age, sex, neutered?

Three things I like about my dog:

Three things I do not like about my dog:

If your other pet is a dog or cat, how does your dog get along with the other pet?

Does your dog play with toys or play games?

Yes No

If so, what are his favorite toys/games? (These may be interactive games like tug or toys he plays with alone.)

What other activities does your dog enjoy?

If group class, did you complete the course?

Yes No

Training methods used (check all that apply): Please check all that apply

Food treats Praise Verbal corrections Physical corrections

List organization name and/or trainer’s name:

Sit %

Down %

Stay %

Come %

Walk nicely on leash %

Leave it %

Give %

Wait %

Go to your place %

Quiet %

Off (furniture or when jumps up) %

Others (including tricks) %

Describe Here

List any procedures/training equipment you’ve used to try to correct the behaviors checked above:

What would you like help with, in order of importance?

Has your dog ever bitten anyone?

Yes No

Any animal?

Yes No

If so, please describe in as much detail as possible:

Has medical attention been necessary (for humans or animals) because of any aggressive incident?

Yes No

If yes, please explain:

What is your dog’s usual reaction when a person he has not met before enters the home?

When was the last time a person unfamiliar to your dog entered the home?

Is there anything else you feel it would be important for me to know?

New Client Intake Form

Phone Number

Email Address

Owner / Head Trainer

Intake Form

Quick links

Areas served