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Assistance Dog Questionnaire
To be completed before commencing Assistance Dog training with Canine Interaction
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* Indicates required question
Email
*
Your email
Participants Name
*
Your answer
Dog's Name
*
Your answer
Dog Breed
*
Your answer
Dog's DOB
MM
/
DD
/
YYYY
Does the dog have any medical conditions? E.G. Food allergies, pain, physical limitations. When did they last see a vet?
*
Your answer
Is your dog up to date on vaccinations and parasite control
*
Yes
No
Maybe
Does your dog have any behaviour problems
*
Your answer
Have you completed any formal training with your dog?
*
Puppy Pre-School
Obedience / Pet Dog Training
Competition Experience
NIL
Other:
How long have you had your dog?
Your answer
Please help our trainer understand how your disability impacts your life and how having a service dog would make a difference for you.
*
Your answer
What behaviours would you find most beneficial in your home
*
Your answer
What behaviours would you find the most beneficial in public spaces/around other people?
*
Your answer
Do you anticipate any changes in your disability that would require additional task training for your potential service dog?
*
Your answer
Our trainer needs to understand if dog training lessons and techniques need to be accommodated to meet your needs. Dog training often involves the following: Select those you may have difficulty with
*
Listening to trainer
Participating in a 1 hour lesson
Watching training demonstrations
Remembering instructions
Bending / Crouching / Sitting to work with the dog
Walking with the dog
Pressing a clicker
Holding a leash
Putting equipment on and off dog (harness/collar/vest etc)
Handing the dog treats
Going to different locations to practice
Picking up after the dog
N/A
Other:
Required
If yes, can you explain the difficulties
Your answer
Do you have support from a licenced health care professional in training a service dog?
Yes
No
Maybe
Clear selection
How would you describe your dog? E.g. Happy, nervous, excitable etc.
*
Your answer
What do you do with your dog for fun?
*
Your answer
What would you like to do with your dog the most?
*
Your answer
What are your goals for the dog during your training?
*
Your answer
Is there anything else we should know about you and your dog?
*
Your answer
Send me a copy of my responses.
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