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About Your Dog Please complete the following information and click "Send Information". This will give me a better understanding of your particular dog and any specific problems you are having in your household. It will also save us valuable time on my first visit. Fill out each field in the form below. If the field doesn't apply to you, type none. First Name: Last Name: e-mail Address: Phone #: Zipcode: Number of adults in household: - Select One - 1 2 3 4 5 6 7 8 Number of children: - Select One - No Children 1 2 3 4 5 6 7 8 Age of children: - Select One - No Children 0-3 0-9 0-14 0-18 3-9 3-14 3-18 9-14 9-18 14-18 Other animals in household: Dog's Name: Dog's Age: - Select One - 0-6 Months 6-9 Months 9-12 Months 1-3 Years 3-6 Years 6-9 Years 9+ Years Breed: Dog's Gender: Male Female Spayed/Neutered?: No Yes How long have you had your dog?: - Select One - 0-3 Months 3-9 Months 9-12 Months 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 8+ Years Where did you hear about my services: - Select One - Association of Pet Dog Trainer List Animal Behavior College Trainer List Internet Search Referral Business Card Other Does your dog have any health problems (i.e. medical conditions, physical injuries, allergies): Please check any of the following problems that your dog displays: Jumping on household members Jumping on guests Chewing inappropriate objects Nipping/Mouthing people Excessive Barking Housebreaking problems Food stealing Guarding Food Guarding objects/toys Digging Leash Pulling Aggression towards household members Aggression towards guests Aggression towards other dogs Other (Please Explain):

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