Behavioral Consult Questionnaire Behavioral Consult InformationOwner First & Last Name* First Last Phone Number*Patient Name* Patient Breed* Approx Age* Approx Age when you got them* Approx weight* Sex* Is you pet spayed or neutered?* Yes No Are you currently treating your pet’s behavior with medication or supplements? List them below. E.g., St.John’s Wort, Adaptil, etc.* Add RemoveWhere did you get your Pet from? Select one. Breeder Rescue Shelter Other Do you have information regarding the littermates of your current pet?* What is your living situation? Please Select one.* House Apartment Duplex Other What was it about your pet that made you choose to bring them into the family?*What are you hoping to get out of this consultation?*Please describe the most urgent behavioral issue that your dog has at the moment.*What other behaviors of your pet are concerning?*How has this behavioral issue affected you and your family? This includes other pets.*If you obtained your pet as a juvenile, describe its behavior. Be detailed. Describe if your pet seemed happy, anxious, excitable, energetic, nervous, etc. Were these emotions or behaviors related to a certain activity, time of day, etc.?*Did you have an easy time teaching your pet where to urinate and defecate? If not, describe the current situation.*Does your dog ever defecate or urinate inside of your home? If yes, describe where it happens and how often.*Have you ever left your pet home alone? Describe their behavior when you were leaving, while they were home alone and when you returned.*How does your pet react to loud noises? E.g., thunderstorms, trucks, doors closing.*How does your pet behave when they see unfamiliar people visit your home and when you are outside of the home?*Is your pet vocal with you? If yes, please describe the situation.*What is your pet’s general activity level?*What type of exercise does your pet get? How frequently and for how long? Be detailed. E.g., on-leash, off-leash, playtime, loose in the yard, etc.*Do you play with your pet? If yes, what type of play and what toys do you use*Do you have other pets at home? List species, age, and breed.*Have you ever owned pets previously? If yes, how was your relationship with them?*Could you please describe the family dynamics within the home? Specifically, who lives with or has contact with your pet, and are there differences in behavior with these different family members?*What attempts have you made thus far and correct your pet’s behavioral issues? Have they seemed to help or hurt?*I understand that my pet must have up-to-date bloodwork, meaning performed within the last 6 months to schedule a behavioral consult.* InitialsI understand that Dr. Redshaw is a behaviorist and not a Trainer. This consultation will refer to positive reinforcement and will not discuss behavioral tools.* Initials Behavioral Consultation Client Consent I am requesting a consultation with Dr. Ashley Redshaw, a Behavior Counselor, to discuss available behavior modifications and medication options for my pet. The consultation may include discussing at-home behavior, anxiety, body language, exercise, and how to monitor your pet’s behavior. I understand Dr. Redshaw is a certified Behavior Counselor with an extensive background and education in a fear-free approach and understanding pets’ behavioral needs. Further, I understand Nevada Veterinary Board Medical laws require my pet to be evaluated within 12 months of my initial consultation with Dr. Redshaw by a licensed Veterinarian. If I am not an established patient of Mountain View Animal Hospital and Holistic Pet Care, I understand my primary veterinarian must submit all Pertinent Medical Records and a Veterinarian Referral Form before I may be scheduled. I understand that the information I receive during my behavioral consultation may be accompanied by appointments with a recommended trainer. In addition, a recheck with Dr. Redshaw may be required to follow up on medications and modifications made during the initial consult. Owner's Signature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
