Dog Intake Questionnaire

Step 1 of 6

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Name*

First Name

Last Name

Address*

Street Address

Address Line 2

City

State

ZIP Code

Phone*

Email*

Dog's Name*

Age*

Sex*

Breed*

Spayed or neutered?*

Yes

Don't know

Is your dog microchipped?*

Yes

Don't know

(All dogs are scanned for a microchip upon arrival at the shelter.)

Microchip number if known

Person name on record with microchip

How long has your dog lived with you?*

Why are you surrendering this dog?*

Where did you get your dog?*

From a rescue group

From a shelter

From a breeder

Other

Which rescue?*

Which shelter?*

Which breeder?*

What do you feed your dog?*

Dry

Wet

Other

Other*

Brand of food*

Does your dog require special medications, special diet, or have special needs?

Has your dog been to a veterinarian?*

Yes

Name of veterinary clinic*

Name of dog as listed with the vet clinic*

Name of person the dog is listed under at the vet clinic*

Describe how the dog behaves at the vet*

Comfortable, easy to handle

Nervous, but okay to handle

Hates going, hard to handle

Other

How comfortable is your dog when you handle their ears/feet/head?*

Comfortable, easy to handle

Nervous, okay to handle

Hates it, hard to handle

Other

Have you ever worked with a professional trainer?*

Yes

Name of trainer*

Have you ever worked with a veterinary behaviorist?*

Yes

Name of the behaviorist*

What other pets has your dog lived with?*

None

Dog(s)

Cat(s)

Other

Other pets*

Describe how your dog behaves with the other pets in your home*

Does not interact with other pets

Okay together even while unsupervised

Okay together when supervised

Shows concerning behavior toward other pets

Please describe concerning behavior

Number of adults in your household*

Number of children under 18*

List ages of children under 18*

Describe your dog's comfort level around children under age 10*

Don't know

Loves kids of all ages

Comfortable with my kids; less so with others

Not comfortable around young children

Other

Does your dog have a fenced yard?*

Yes

What type of fence?*

Does your dog escape the fenced yard?*

Yes

Have you used a crate to confine your dog?*

Yes

Is your dog comfortable with confinement in a crate?*

Yes

For how long?*

Does your dog have any history of aggression?*

Yes

Towards whom?*

Has your dog ever:*

Showed teeth

Growled

Snapped

Bitten

Made you nervous

Has your dog ever bitten or broken skin?*

Yes

Describe the circumstances*

Date of the most recent bite or scratch that broke skin?*

Has anyone needed to get medical treatment?*

Yes

Please describe*

How does your dog react to other dogs?*

Does not have interest in other dogs

Friendly with other dogs

Pulls on leash to meet other dogs

Barks at other dogs

Is uncomfortable meeting other dogs

Is aggressive towards other dogs

What type of dogs are they uncomfortable meeting?*

Small dogs

Big dogs

What type of dogs are they aggressive towards?*

Small dogs

Big dogs

How does your dog react to meeting strangers?*

Likes everybody

Shy initially, but then okay

Indifferent

Fearful

Aggressive

Okay with men

Not okay with men

Okay with women

Not okay with women

Other

Please elaborate*

Has the dog ever displayed any possessive behavior?*

Yes

Toward what?*

Food or chews

Toys

Family members

Property/fences

Car

Other pets

Other

Please elaborate*

Does the dog chase anything?*

Yes

What does the dog chase?*

Cats

Small Animals

Cars/Motorcycles/Bikes

Children

Joggers

Other

Describe*

Has your dog ever made contact with what they chased?*

Has never made contact

Made contact and was friendly

Made contact and was unfriendly

Made contact and caused harm

Describe*

My dog is*

Calm & quiet

Energetic

Playful

Shy

Affectionate

Social & friendly

Independent

Confident

Nervous

Vocal

Other

Please elaborate*

Does your dog know any commands or tricks?*

Don't know

Yes

Please list*

What are your dog's best qualities?*

What are the most difficult qualities?*

Other information you would like to share

Photos (optional)

Drop files here or

Accepted file types: jpg, jpeg, png, Max. file size: 64 MB, Max. files: 2.

Photos are NOT required as part of our intake process. For pet owners who want to share photos, you can upload 1-2 photos here.

Dog Intake Questionnaire

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