Separation Anxiety Modification Albany NY | Dog Behavior Modification Albany NY | Dog Training Albany New York

Separation Anxiety Evaluation Registration

Today's Date*
MM slash DD slash YYYY
Client's Name:*
First Last
Client's Address:*
Street Address City State ZIP Code
Home Phone:*
Cell Phone:
Email*
Enter Email Confirm Email
How did you learn about All Dawgs?*
- Event
- Referral
- Returning Client
- Social Media
- Web Search
What event did you meet us at?*
Who referred you to All Dawgs?*
- Friend
- Pet Store
- Shelter or Rescue Organization
- Vet's Office
Please list your friend's first and last name so we may thank them for referring you.*
Which pet store referred you to All Dawgs?*
Which shelter or rescue organization referred you to All Dawgs?*
Which vet's office referred you to All Dawgs?*
What is the name of your vet hospital?*
What's the name of your vet?*
May we share information with your vet on your dog's separation anxiety modification?*
- Yes
- No
Would you like to receive our e-newsletter?*
Dog's Information
Dog's Name:*
Dog's Date of Birth*
MM slash DD slash YYYY

Please put best guess is adopted
Dog's Breed:*
Dog's Gender:*
- Female - Intact
- Female - Spayed
- Male - Intact
- Male - Neutered
Does your dog have any type of medical issues?*
- Yes
- No
Describe your dog's medical issues*
Has this dog growled, lunged at, snapped or bitten a person?*
- Yes
- No
Please explain this dog's issue(s) with people.*
For safety reasons, I understand that I may be required to purchase a muzzle approved by All Dawgs and train this dog to be relaxed in muzzle prior to the first lesson. The muzzle must be worn until my trainer grants its discontinued use. I understand that failure to follow this safety protocol may cause training may be discontinued without any refunds (Please initial).*
Does this dog have any issues guarding objects, people and/or spaces towards a person or another dog?*
- Yes
- No
Please explain your dog's issues with guarding objects, people and/or spaces.*
Does this dog enjoy being around other dogs?*
- Yes
- No
Please explain what happens when your dog is around other dogs.*
Does your dog display any obsessive compulsive behaviors such as include acral lick dermatitis, flank sucking, pacing, circling, incessant or rhythmic barking, fly snapping or chasing unseen objects, freezing and staring, excessive drinking, sucking, licking, or chewing on objects (or owners), tonguing or licking the air and other forms of self mutilation.*
- Yes
- No
Please describe what obsessive compulsive behaviors your dog has.*
Separation Anxiety Information
Please check any of the following symptoms your dog displays when left alone at home:*
- Aggression
- Barking, whining and/or howling (intermittent)
- Barking, whining and/or howling (constant)
- Chewing (on bedding, shoes but NOT on points of entry)
- Chewing (at points of entry)
- Chewing (at points of entry with substantial damage to property)
- Diarrhea or vomiting
- Drooling
- Excessive greeting (settles in 1-2 minutes)
- Excessive greeting (settles in less than 10 minutes)
- Excessive greeting (takes more than 10 minutes to settle)
- Excessive shedding
- Excessive water consumption (upon owner's return home)
- Is okay when left with any person
- Licking or chewing that causes sores (typically legs or tail)
- Owner shadowing (but will not follow when asleep)
- Owner shadowing (will wake from sleeping to follow owner)
- Pacing
- Panting
- Pees and/or poops when left alone
- Pre-departure anxiety (such as trembling before you leave)
- Sweaty paws
- Tries to escape (the crate, room and/or the house causing harm to themselves and/or property)
- Won't eat when left (even high value treats)
How long has your dog experienced the above symptoms?*
Has your dog's symptoms improved, stayed the same or worsened over time?*
- Improved
- Stayed the Same
- Worsened
Please describe whatever participating events may have cause the separation anxiety:*
Does your dog display signs of separation anxiety if you are in another room with the door closed?*
- Yes
- No
Does your dog following you from room to room?*
- Yes
- No
How many times per week do you leave your dog home alone?*
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
How long are the absences?*
How long can your dog be left alone without showing any of the above symptoms?
Where does the dog stay when left alone?*
- In a crate
- Confined to a room (such as a bedroom or kitchen)
- Given the whole house
Will your dog eat treats, food, chewies and/or Kongs during your absences?*
- Yes
- No
Does your dog display any signs of separation anxiety if others are present during your absences? (i.e. such as a friend at your house)*
- Yes
- No
Does your dog display any symptoms of separation anxiety if left alone in a car?*
- Yes
- No
What symptoms does your dog display when left alone in a car?*
Have you done any crate training with this dog?
- Yes
- No
Is your dog comfortable in a crate when you are at home?*
- Yes
- No
- My dog is never crated when I am home
Can you close the bathroom door on this dog while showering?
- Yes
- No
Where is the dog when you come out of the bathroom?*
What type of exercise does your dog get and how often?*
Is this dog on any medication for separation anxiety?
- Yes
- No
What medication is this dog taking?*
When did this dog start taking this medication?*
MM slash DD slash YYYY
Have you done any formal training with this dog?*
- Yes
- No
What types of training has this dog have? Check all that apply:*
- Group Class
- Private Lessons
- Board & Train Program
Do you know what cues will cause your dog to display anxiety?*
- Yes
- No
Please list the cues will cause your dog to display anxiety? (i.e. picking up your keys, putting on your coat, etc?) Click the plus key (+) for additional rows.*
Does your dog display the same level of separation anxiety symptoms if left in the morning versus being left in the evening?*
- Yes
- No
Are there any types of absences your dog appears not to get anxious about? (i.e taking out the garbage)*
- Yes
- No
Please list when you can be absent from your dog without him getting anxious*
Describe what a typical weekday day entail for you and your dog.*
Describe what a typical weekend day entail for you and your dog.*
Have you ever had a complaint from your neighbors regarding your dog's separation anxiety?
- Yes
- No
Will your neighbors (or landlord) affect your ability to work on your dog's separation anxiety?
- Yes
- No
Please explain what affect your neighbors and/or landlord will have on your ability to work on this issue.*
Are you able to re-arrange your schedule to avoid leaving your dog alone below the time limit where your dog does not have symptoms for a few weeks or more?*
- Yes
- No
Are you able to use our daycare and/or dog walking services to keep your dog from having to experience absences where your dog experiences symptoms for a while?*
- Yes
- No
Have you worked on your dog's separation anxiety previously?*
- Yes
- No
Did you work on this issue by yourself or with another trainer?*
- By Myself
- With another trainer
Who did you work with before?*
What kind of things did you do? What were the results?*
Does your dog have any issues being touched or handled?*
- Yes
- No
Please explain your dog's issues being touched or handled.*
What are your goals for this dog one year from now?*
Continued Reinforcement*
By checking this box, you affirm that you understand that without continued reinforcement and consistency from the Owner, training results will not be permanent.*
Recording Consent*
By checking this box, you agree that all remote sessions will be recorded. This includes the evaluation.*
Cancellation Policy*
By checking this box, you acknowledge that you understand there is a no cancellation policy for lesson appointments. This includes reschedules.*
Accuracy of Information*
By checking this box, you affirm that the above information is accurate to the best of your knowledge.*

Registration: Separation Anxiety Modification

Separation Anxiety Evaluation Registration

Dog's Information

Separation Anxiety Information

Serving the Capital District Since 2007