Behavior Questionnaire
Instructions: Fill out Questionnaire, choose Accept & Submit. After reviewing, I will contact you to schedule an Evaluation. Cost is $100. For more info, go to "Behavior" page under "Specialties"
 
Owner First Name
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Last Name
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Address
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City
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State
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Zip
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Home Phone
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Cell Phone
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Email
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Phone
List Names, Ages & Relationship of everyone in Home
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Describe your living situation (apt. condo, house)
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How Did you Find Us?
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Dog's Name
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Dog D/O/B
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Breed
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Is dog Spayed or Neutered?
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Vet's Name
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Vet's Phone
Is dog current on Bordetella, Rabies & Distemper?
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How long have you had this Dog?
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Has this Dog had other Owners? If yes, how many & how long
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How many other Dogs do you have? Describe
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What are the Behavior Issues?
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What Interventions have you tried? Describe
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Have you had any recent life changes (Divorce, death, move, etc)
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Have you worked with another trainer? Describe
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How do you correct your dog for something you don't like? How often? Which behaviors?
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Describe any electronic fencing, collars or other electronic corrective devices you have used?
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How do you reward behavior that you like? How often & which behaviors?
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How is Dog around small children?
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Has Dog bitten any Humans? Describe
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Has Dog bitten other Dogs? Describe each incident & detail if Vet visit necessary
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What brand of food does Dog eat?
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Do you free feed or break up into meals?
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Any digestion issues?
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Does Dog have Allergies? Describe
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Does Dog have Pre-existing Medical Conditions? Describe
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Is Dog on Medications? List
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Is Dog anxious in your absence or in car? Describe
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How does your Dog act on Leashed Walks? Describe
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Do you do Off-leash walks?
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If so, does Dog return immediately when called?
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How often does your dog meet New Humans & Dogs? Describe
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How much time does dog spend outside?
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How much time does dog spend inside?
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What Commands & Tricks does dog know?
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What is Dog's favorite game?
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What do you like BEST about this Dog?
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Ideally, what do you want dog to do instead of the unwanted behaviors?
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WAIVER
I hereby acknowledge I have voluntarily applied for dog owner/handler training, fitness, or related services, conducted by Canine Culture, LLC. I fully understand that such training and services pose numerous risks to the health and safety to myself and my dog. I freely and knowingly assume these risks, which include, but are not limited to, the following representative examples, which are not intended to be all-inclusive: the risks of the owner/handler being bitten, scratched, soiled, tripped, yanked, jerked, attacked, frightened, or otherwise injured by other dogs in the classes, or by the owner/handler's own dog; the risks of tripping over or slipping upon floor matting, dogs, or dog-training related objects, or slipping on dog drool or dog solid or liquid waste matter, or colliding with dogs, other human participants, dog training props, dog jumps, dog obstacles, dog gating or building parts, including but not limited to, walls, doors, and support beams. I do not hold Canine Culture, LLC, its members, officers, agents trainers, and employees responsible for any damages, injuries, or liabilities caused by my animal. Also, I will not hold Canine Culture, LLC, its members, officers, agents and employees legally or financially responsible for any injury to my dog or myself. I understand that I am responsible for my dog and its actions, and understand that the Colorado Dog Bite Law holds me responsible to pay compensation for any injuries sustained to any person other than the trainer. I give Canine Culture, LLC my permission to use any photos or videos of myself & my dog for marketing and/or training purposes.
REFUNDS: are given only in case of medical or other emergency. By applying for a Behavior Evaluation you are reserving a spot in my Schedule. Full Refunds given with 24 hrs notice.
 
Cost is $100
 
 
 
 
YOUR EXPERIENCED CANINE EDUCATOR
CANINE CULTURE, LLC
Laura Bussing