Pet Assistance Request Form

*1.
Question - Required - Please indicate the reason for surrender:
Please make at least 1 selection from the choices below.

*2.
Question - Required - We may have alternatives to help keep your pet in your home or provide you with information to find him or her a new home without having to enter the shelter. Would any of the following resources help you be able to keep your pet in the home? Check all that apply:
Please make at least 1 selection from the choices below.

 


DESCRIPTION AND BASIC HISTORY
*3.  


*4.  


*5.  


*6.  


*7.


*8.


*9.


*10.  


*11.


12.

(Maximum response 255 chars, approx. 5 rows of text)

*13.

(Maximum response 255 chars, approx. 5 rows of text)

*14.


*15.


*16.

*17.

*18. How would you describe your dog with children?
(Select one of the available choices or enter a different value.)



*19. In your opinion, what ages of children would live safely and happily with this dog?
(Select one of the available choices or enter a different value.)



*20.
Question - Required - What other animals has your dog lived with? (Check all that apply)
Please make at least 1 selection from the choices below.

*21.

(Maximum response 255 chars, approx. 5 rows of text)

*22.

(Maximum response 255 chars, approx. 5 rows of text)

*23.

*24.


*25.
Question - Required - When alone, where is your dog kept?

26.


*27.


28.
Question - Not Required - When left alone, does your dog display any of the following behaviors? (check box all that apply)

29.

(Maximum response 255 chars, approx. 5 rows of text)

*30.


*31.
Question - Required - If your dog is not potty trained, please check all that apply
Please make at least 1 selection from the choices below.

*32. When do most accidents occur?
(Select one of the available choices or enter a different value.)



*33. How is your dog confined to your property when outside?
(Select one of the available choices or enter a different value.)



*34.

(Maximum response 255 chars, approx. 5 rows of text)

*35.


36.
Question - Not Required - When unsupervised outside, does your dog do any of the following?
Please make at least 1 selection from the choices below.

37.

(Maximum response 255 chars, approx. 5 rows of text)

*38.


39.


40.


41.


42.


43.


44.
Question - Not Required - Does your dog do any of the following while playing? (Check all that apply)
Please make at least 1 selection from the choices below.

45.


46.
Question - Not Required - What games does your dog like? (Check all that apply)

47.

48. What types of exercises does your dog receive on a regular basis? (Check all that apply)
(Select one of the available choices or enter a different value.)



49.

 


BEHAVIOR AND TRAINING
50.


*51.

52.
Question - Not Required - What commands does your dog know? (Check all that apply)

53.


54.
Question - Not Required - Describe your dog's behavior in the car

  How does your dog usually behave with the following?
55.
Question - Not Required - Familiar Men










56.
Question - Not Required - Familiar women










57.
Question - Not Required - Unfamiliar men










58.
Question - Not Required - Unfamiliar women










59.
Question - Not Required - Babies










60.
Question - Not Required - Toddlers










61.
Question - Not Required - Children










62.
Question - Not Required - Other dogs










63.
Question - Not Required - Cats










64.

(Maximum response 255 chars, approx. 5 rows of text)

65.

(Maximum response 255 chars, approx. 5 rows of text)

66.

(Maximum response 255 chars, approx. 5 rows of text)

67.

  How does your dog react to the following? 
68.
Question - Not Required - People touching/taking food, bones, toys, other items

69.
Question - Not Required - Other pets touching/taking food, bones, toys, other items

70.
Question - Not Required - Familiar people approaching owner/family

71.
Question - Not Required - Unfamiliar people approaching owner/family

72.
Question - Not Required - Familiar people entering home/yard

73.
Question - Not Required - Unfamiliar people entering home/yard

74.
Question - Not Required - Restraining/Hugging

75.
Question - Not Required - Grooming/Brushing

76.
Question - Not Required - Clipping nails/handling paws

77.
Question - Not Required - Pulling/grabbing collar

78.
Question - Not Required - Scolding/Punishing

79.
Question - Not Required - Excessive/rough petting

80.
Question - Not Required - Touching a certain body part

81.

82.


83.
Question - Not Required - If yes, what kind of resources does your dog guard?

84.

(Maximum response 255 chars, approx. 5 rows of text)

85.

(Maximum response 255 chars, approx. 5 rows of text)

 
 
 
HEALTH AND MEDICAL HISTORY
86.
Question - Not Required - Does your dog have recent or ongoing history of any of the following conditions? (check all that apply)

87.

(Maximum response 255 chars, approx. 5 rows of text)

88.

(Maximum response 255 chars, approx. 5 rows of text)

89.


90.

91.

 

Please indicate your dog’s behaviors toward a groomer or veterinarian
92.
Question - Not Required - Examination

93.
Question - Not Required - Restrain

94.
Question - Not Required - Administer shots

95.
Question - Not Required - Trim nails

96.
Question - Not Required - Groom/Bath

97.
Question - Not Required - Take blood

98.


99.

100.


101.

(Maximum response 255 chars, approx. 5 rows of text)

   Please leave this field empty