Fear or Aggression Intake Form
Client & Dog Information
Guardian’s Name:
Date:
Home Phone:
Address:
Cell Phone:
Email:
How did you hear about us?
Dog’s Name/ ID:
Breed/Age/Sex/:
Date of adoption:
Is your dog spayed/neutered?
Age of dog upon entering your home:
How did you acquire your dog?
Children in the household?
If yes, please list names and ages:
Other pets in the household?
If yes, please list type, breed, age, sex, and if spayed or neutered:
What is the chief behavioral complaint that has caused you to seek our assistance?
When did this behavior start?
How long has this behavior been occurring?
When did you first notice this behavior?
What is the worst the behavior has gotten?
What have you tried to correct his behavior and what were the results of your efforts?
Do you have an electric fence?
Do you now use, or have you ever used a shock collar in the past on your dog(s)?
Do you use choke chains (collars) with your dog(s)? If yes, please explain why and how you use this
tool.
Who is your veterinarian?
Name of Clinic?
lmatthews@pawsitivepractice.com 404-353-2416 www.pawsitivepractie.com
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Have you spoken to your vet about the specific problem for which you are seeking our help?
What did your vet suggest you do about the problem?
Did your vet do any medical testing (blood work or other) to rule out underlying medical issues that
may be related to the concerning behavior your dog is displaying?
If so, what were those results?
May we freely exchange information with your veterinarian when necessary?
Does your dog have any current health issues? If so, what?
Is medication currently being used?
If so, what medication is it, at what dosage, and for what issue?
Dog’s Routine
What food is your dog eating, how much, and how often?
Do you leave food down all day?
Describe the daily exercise routine for your dog(s).
When you leave the house, where is your dog kept and for how long?
What kinds of toys, chews, etc. does your dog or pack play with, and how often?
Is your dog treat motivated, and are there any known food allergies?
Describe any guarding (protecting) of food or toys and tell me how long it has been happening:
lmatthews@pawsitivepractice.com 404-353-2416 www.pawsitivepractie.com
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Training History/Reinforcers
Have you done any prior training with your dog(s)?
Where did you do the training?
What treats does your dog like best?
Can you describe the basic approach you use to train your dog?
Did you feel you got the results you were looking for from your training efforts? Why or why not?
Reactivity:
Aggressive to other dogs? X all that apply: (X goes before the item)
_____while walking by other dogs ___ while walking by other dogs but only while on leash
______ when interacting with other dogs (period) ___ people passing by our home _____while in the car and
pass dogs
Describe the behavior:
_____________________________________________________________________________
Leash walking
_______pulls – strong/wild/unmanageable ___ jumps up on walker ___ mouths lead or person
_______fearful of environment ______ fearful of other people _____fearful of other dogs
_____fearful of novel objects (statues, balloons tied to mailbox, etc.) _________ fearful of noises
Describe the behavior: ______________________________________________________________
Aggressive to people? X all that apply: (X goes before the item)
_____Men ____Women_____Children ______older people who walk differently______people walking past the
territory (including your car) _______people approaching to pat your dog _____people moving suddenly
________people dressed in a certain way (uniforms, sunglasses, hats, backpacks) ______ people who desire to
enter your home __________family members: name them please:____________________
Environmental Sensitivity: Dog is fearful or reacts to:
_________thunder ________rain ________wind _______water _______ other ________please name it: _______
BODY PART SENSITIVITY: Please don’t touch my:
__________head _______ears _______nose ______eyes _______mouth ______front paws _______back paws
tail _______chin ________neck _________belly ___________hind end _________teeth
General Comments: Please indicate ANY unusual or problematic behaviors not mentioned before.
lmatthews@pawsitivepractice.com 404-353-2416 www.pawsitivepractie.com
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Bite Levels/Bite History
Number of bites your dog has completed and on whom? ____________
What is the WORST result that has occurred so far?
1) snap – no contact
2) contact with zero damage or light scratch
punctures
4) 1 to 4 deep punctures and/or bruising (stitches required)
5) deep bi-directional tears (dog shook his head while attached)
fatality or mutilation
3) 1 to 4 shallow
6) multiple level 4s or 5s
Has your dog ever been quarantined for any reason? If yes, please explain:
Description of Bite Incident(s)
Describe each bite incident.
Location(s) where the incidents occurred:
Person/People or Dogs involved: ______________________________
Bite recipients were :
nearly always men
known to the dog
men and women
children
strangers to the dog
Have you noticed anything similar about the situations, people, or dogs that were involved across the
biting incidents? (examples: all were men, all were leaning over the dog, reaching over the head, all at
the front door, all while on leash, when a certain dog or person approached or was waking away, etc.)
Have you noticed any escalation or change in your dog’s behavior over time?
Have you noticed any triggers for the aggressive/reactive behavior? If so, what are the triggers?
lmatthews@pawsitivepractice.com 404-353-2416 www.pawsitivepractie.com
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Stress/Warning Signs/Precursor Behaviors
Have you noticed any of these warning behaviors before an aggressive incident breaks out?
freeze
bark
lunge
growl
snarl
snap
muzzle punch
retreat
bite
Resource Guarding
Did any or could any of the incidents have involved protection highly items such as the following?
Check all that apply.
toys or other objects
none
food
treats or chews
favorite spot
favorite person
Handling
Are any of the following a problem for your dog(s).
Touching . . .
paws
tail
or giving a:
ears
hug
muzzle
head
collar grab … or
rump
other:
being reached for or towards?
none
Undersocialization/Fear
Did any of the aggressive incidents involve:
men
women
uniforms
children 0-3
unusual gaits
children 4-10
children 10+
hats
glasses
unusual human behavior:
other:
none
Sudden Environment Contrast
Did any of the incidents involve someone:
changing positions (sit to stand, stand to sit, etc.)
re-entering the room or reappearing
up high (on a ladder, etc.)
partially obstructed (behind a wall, etc.)
carrying something (large bag, backpack, groceries, etc.)
loud noises
other:
none
How would your dog(s) react if you and I were seated, and I suddenly stood up?
How would your dog react if I walked out of the room we were in and then returned a few minutes
later?
lmatthews@pawsitivepractice.com 404-353-2416 www.pawsitivepractie.com
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Movement Sensitivity/Predation
Have any of the reactive incidents involved:
joggers
bicycles
skateboards
children running
children screaming
other:
none
Client’s Goals
What goals would you like to see your dog(s) achieve during training? For any behaviors you would like
to see diminished or extinguished, describe what you would like to see your dog do instead.
Is there anything else that you would like to mention?
Other Dogs In Your Home
Are there any other dogs in your home who you or others would describe as shy, fearful, anxious, or
aggressive?
If so, describe how you feel this may be impacting the dog you are seeking help for today.
Other People Visiting Your Home
Describe your process for bringing new people into you home with your dog(s):
lmatthews@pawsitivepractice.com 404-353-2416 www.pawsitivepractie.com
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Liability Waiver & Policies
1.
Lisa Matthews of Pawsitive Practice Training, LLC will endeavor to create as safe an
environment as possible for the training of my dog and will offer only sound, safe, and
responsible training and training instructions. However, I recognize that neither Lisa
Matthews nor Pawsitive Practice Training, LLC is responsible for any unintentional
errors, omissions, or incorrect assertions. I understand that the recommendation of any other
product or service is not a guarantee of my satisfaction with that product or service. Further, I
am and will remain responsible for the actions of my dog at all times and I hereby agree to
indemnify and hold harmless Lisa Matthews or Pawsitive Practice Training, LLC of any
and all claims of injury, expense, costs, or damages caused by the actions of my dog while
under Lisa Matthews’ instruction or control and under my own care as a result of following
training instructions. I understand the inherent risks of owning a dog, including but not limited
to the risk of dog bites to others or myself.
2. Additionally, I attest to the fact that if there is an electric fence on my property, I will either
turn it off or remove my dog’s collar during training sessions with Lisa Matthews under this
contract. Failure to do so will terminate this training agreement immediately with no money
refunded.
3. I understand that I am to use a basket muzzle, flat collar, body harness, martingale collar,
Halti, or Gentle Leader during my training sessions if necessary. Using a choke, pinch, electric,
or spray collar during my training sessions will immediately void this contract with no money
refunded.
4. I understand the behavior of a moment-to-moment decision-making animal can never be
guaranteed. Therefore, the success of my dog is highly correlated to the amount of time I spend
practicing the desired behaviors with my dog, the degree of consistency family members and I
employ, and my willingness to take a leadership role with my dog – one of firmness, fairness,
and benevolence.
Initial:
MEDIA RELEASE: I hereby give my full consent to all photographs, audio recordings,
academic work, and/or video recordings taken of me, my dog(s), friends, and family members
(including minor children) by Lisa Matthews, Pawsitive Practice Training, LLC or their
designee. I understand that any such photographs, audio recordings, academic work, and/or
video recordings become the property of Lisa Matthews, Pawsitive Practice Training, LLC and
may be used without consent, for educational, instructional, or promotional purposes as
determined by Lisa Matthews, Pawsitive Practice Training, LLC in broadcast and electronic
media formats now existing or in the future created.
Initial:
2. Payment Policy:
Payment (check, cash, or money order) is due in full on or before the first training session.
Initial:
3. Cancellation Policy: READ CARFULLY!
1. Once sessions have started, there are NO refunds.
2. The client may reschedule or cancel ONE prescheduled session without penalty. Any
subsequent reschedules or cancellations will count as and be charged as a prepaid session in
the training plan. To continue training with Pawsitive Practice Training, LLC, the client must
schedule the subsequent appointment within 72 hours or pay the full hourly rate for the next
training appointment. It is imperative that sessions be scheduled on a consistent basis and in a
timely manner. More than two rescheduled or canceled appointments will void all contracted
services with Pawsitive Practice Training, LLC. Additionally, failure to complete a training
program within three months from date of initial consultation may be construed as a
termination of services and will relieve Pawsitive Practice Training, LLC from any further
obligation to the client, deeming all paid fees non-refundable.
Initial:
This contract is validated by the initials above and also serves as approval for future services without additional
written authorization.
lmatthews@pawsitivepractice.com 404-353-2416 www.pawsitivepractie.com
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Just in case we need to use a basket muzzle at some point, here is a fantastic link
explaining the most appropriate, step-by-step desensitization process. I will let
you know if this applies to your case so that you may get started with this
desensitization process. Basket muzzles are sold at most local PetCo stores.
For brachycephalic dogs (Boston Terrier and Pugs) dogs with squished in noses,
morrco.com
Link to video to help your dog get used to the muzzle and should be practiced for
at least one week before we arrive:
http://www.youtube.com/watch?v=1FABgZTFvHo
Thank you for taking the time to fill out this questionnaire. Please email it back to me at
lmatthews@pawsitivepractice.com
Upon receipt of this returned document, I will call, text, or email you within 24 hours and set
up the behavioral evaluation. Please include your availability to get started in your return email
to me. I will look into my calendar and offer you my first available appointment.
Warmest regards,
Lisa Matthews
lmatthews@pawsitivepractice.com 404-353-2416 www.pawsitivepractie.com
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