One to One Behaviour Modification Assessment / Intake Form You must complete this form below ahead of any one to one session taking place. First Name *Email Address *Phone NumberDog DetailsNameBreedAgeSexMaleFemaleNeutered / SpayedNeutered / SpayedYesNoUnsureIf your dog neutered or spayedGive a detailed description of the behaviour that is of concern0 / 180Bite HistoryIf applicable please indicate at which of the following levels your dog has bitten, how many times, and give a description of each of the circumstance in which it happened, including events leadingup to the bite:Level 1 (Pre Bite): Snapping (air bite, no contact)Level 2 (Near Bite): Tooth contact on skin but no punctureLevel 3 (3a): Skin punctures, single bite (all punctures shallower than the length of the canine tooth)Level 3 (3b): Skin punctures, multiple bites (all punctures shallower than the length of the canine tooth)Level 4 (Very serious): Single bite with punctures deeper than the length of the canine (the dog bit and clamped down) or with slashes in both directions from the punctures (the dog bit and shook his head)Level 5 (Very serious): Multiple bite attack with deep punctures, or multiple attack incidentLevel 6 (Death): Victim killed or flesh consumedDetails of Bit HistoryEnvironmental AssessmentFamily UnitPrimary CaregiverOther Family MembersNameAgeRelationship to CaregiverInvolved in training / caregiving?YesNoHousehold DogsEnter details below of any other dogs in the house (if applicable)Dogs NameBreedAgeSexMaleFemaleNeutered / SpayedNeutered / SpayedYesNoUnsureRelationshipRelationshipSiblingChildParentRelationship to the dog you're admitting.Early Socialisation Period 3 to 12/16 weeks (If known please give us some background on the following)Breeding facility, including if in shed, kennel etc:Was the pup from a rescue background? If so please give as much info as possibleDid you meet the parents, and if so, what was your impression?At what age did you get the pupIs there any event that stands out as having had a possible impact on the pupAdolescent and Adult Period: 6 months +If know is there event that stands out as having had a possible impact on the dogDietFood Brand & Composition (WhatsApp or text picture of composition breakdown, this is normally found in small print either on the back or the side of food packaging)If you feed cooked please give detailsIf you feed raw please give detailsWhat treats do you give your dog, how often and whereWhen does feeding happenHow does feeding happen, is the dog fed from a normal food bowl, interactive feeders such as Kong Wobbler, snuffle mat, licky mat, etcPhysical ActivityWould you describe your dogs lifestyle as very active, active, medium or not active at allYesNoWhat type of physical activity does your dog get, how often and for how longIf walking, is it on or off leadOnOffPlay: describe what type of play your dog enjoys, eg. Playing alone, with other dogs, with humans, tug of war, fetch, chase, etcWhat type of toys does your dog like to play withSocial InteractionWhat level of social interaction does the dog have with the family, e.g. Does it sleep in the house and if so where, time spend with the family, how long, where, and whenTrainingPlease give us information on any formal or informal training your dog has doneBehaviour ModificationPlease give us information on any behaviour modification programmes you may have done with the dog beforeSend Message
