Behavior Treatment Application Form

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IMPORTANT - PLEASE READ BEFORE FILLING OUT THE FORM

Please complete this questionnaire as thoroughly as possible. All of your answers will be confidential. The details you provide will give an initial understanding of your dog's problems. Please collaborate with others in your home, more information, as well as more perspectives, will make a bigger difference. If you do not know the answer to any of the questions, please write in UNKNOWN.

It is important that your dog's regular veterinarian stay informed. This will be especially important if medications are recommended or if there is a physical component to the behavior concern. I will email the follow-up behavior plan to your veterinarian for their records following the consultation. You may need to report to your veterinarian as we progress. I will consult with you on the behavior issues until we get the best possible result. If there are more serious neurological issues suspected, a referral to a Board Certified Veterinary Behaviorist may be suggested.

**INCLUDED IN THE APPROXIMATELY 1 HOUR CONSULTATION:
Video and form review, follow up research, three progress check-in emails
Detailed behavior treatment plan sent to you & your veterinarian for their records.

Due to the severity of behavior issues and safety protocols that must be adhered to, the person filling out this form, must be at least 18 years of age.

** AFTER YOU SUBMIT YOUR FORM, I WILL EMAIL YOU WITHIN 24 HOURS. PLEASE CHECK YOUR SPAM EMAIL FOLDER IF YOU DO NOT SEE MY RESPONSE IN YOUR INBOX - THE EMAIL WILL BE COMING FROM - (thebalancedpack.wa@gmail.com)

Email *

PLEASE CHOOSE THE SERVICE YOU PREFER:

Please note, the in-person service area included in the consultation is within 30 miles round trip from Wapato Park, Tacoma, WA.

If you are located outside this area, I am happy to travel to you, and a travel fee will be added to the service.

Virtual - 1 hour consultation- Best option for dogs that might bark through out the consultation.

In-Person - 1 hour consultation- I come to your home. ** Please note, if there is a bite history towards people, your dog must be safely secured, and wear a muzzle.

Name, occupation of person filling out this form *

Main Cell phone: *

Alternative Contact Phone (optional)

Physical Home Address: Please include City and State

Name of regular veterinary clinic *

What is your living arrangement? *

Apartment

Townhome/Condo

House with Small Fenced Yard

House with Large Fenced Yard

Farm/Ranch with a lot of property

House with Yard that is not fenced.

Please list all people who are living in the household. Name - Relationship to you - Occupation - Work from home/or leave house for work. Please list children's ages if under 16 years old. Please include anything you think is important for me as a dog behavior consultant to know about the people in your household. *

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