Prospective Client Questionnaire Let me know a little more about you and your dog. If your dog is suffering from separation anxiety and you would like us to consider working with you, please take the time to fill out the following questionnaire. Filling out this questionnaire does not guarantee that we will be able to accept you as a client. We look forward to assessing your case and seeing if we can assist you! Thank you.Client(s) Name(Required) Email(Required) Enter Email Confirm Email Phone(Required)Confirm Phone(Required)City(Required) State(Required) Country(Required) Dog's Name(Required) Age of Dog(Required) Sex of Dog(Required) Male Female Where was dog acquired?(Required) Shelter Breeder Other Breed Type or Mix Type(Required) How long has dog been in your household?(Required)Select< 3 wks.< 1 mo.< 3 mo.3 - 6 mos.6 - 11 mos.1 yr.2 yrs.3 yrs.4 yrs.5 yrs.6 yrs.7 yrs.8 yrs.9 yrs.10 yrs.11 yrs.12 yrs.13 + yrs.How often is your dog being left alone currently?(Required)SelectNone< 1 hr.1 - 2 hrs.2 - 4 hrs.4 - 6 hrs.6 - 8 hrs.8+ hrs.If you have any additional comments regarding your dog’s current alone time, please enter those here. Can you adjust your schedule so that your dog will not have to be left alone during training for a while?(Required) Yes No Maybe Please keep in mind, dog is not considered alone when accompanied by someone, in or outside of your home, in an environment where they are comfortable.Have you done any previous training to address your dog's separation anxiety?(Required) Yes No If you answered 'yes' to the above question, please explain.Have you discussed your dog's separation anxiety with your veterinarian?(Required) Yes No If you answered 'yes' to the above question, please explain.How long would you like to be able to leave your dog alone in the future?(Required)Select< 1 hr.1 - 2 hrs.2 - 4 hrs.4 - 6 hrs.6 - 8 hrs.8+ hrs.If you have any additional comments regarding your dog’s future alone time, please enter those here. Please let us know how you heard of us.(Required) Friend/Colleague/Relative Online Search Facebook Trainer Newspaper or magazine (i.e.- Washington Post, The Bark) 'Treating Separation Anxiety in Dogs' Book Other If applicable, please provide the name of your referral below. I understand that email replies, registration and payment confirmations may go to my Spam/Junk folder.(Required) Yes Please click on Submit Query when you have finished with the form. We appreciate your time and will get back to you as soon as we can! (Hang in there!!!)CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
