SEP ANXIETY CLIENT QUESTIONNAIRE

SEPARATION ANXIETY CLIENT QUESTIONNAIRE

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

DOGS NAME *

DOGS BREED *

DOGS AGE / DOB *

GENDER *

HOW LONG HAVE THEY LIVED WITH YOU *

WHAT MAKES YOU SUSPECT YOUR DOG HAS SEPARATION ANXIETY? *

DO YOU LEAVE YOUR DOG HOME ALONE? *

YES NO NEVER TRIED

IF YES HOW LONG? *

CURRENTLY WHAT HAPPENS OR WHAT DO YOU COME HOME TO? *

HOW OFTEN / HOW LONG DO YOU NEED TO LEAVE YOUR DOG ALONE - IN THE FUTURE? *

HAVE YOU DONE ANY TRAINING SO FAR TO ADDRESS THE SEPARATION ANXIETY? Please explain *

ARE YOU ABLE TO SUPEND LEAVING YOUR DOG HOME ALONE DURING THE TRAINING PROGRAM Choose One *

YES NO DON'T KNOW

OTHER COMMENTS *

Submit