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Behavior Modification History Form

Specifically for dogs who are struggling with behavior problems like reactivity, aggression, resource guarding, phobias, anxiety, obsessive behaviors, and similar.

New Client Application--Behavior Modification

Human Information

Basic Contact Information

Name(s) *

Dog Name(s) *

Address (street) *

Address (City and Zip Code) *

Email Address(es) *

Phone Number(s) *

Please note your preferred phone number

How did you hear about us? *

Emergency Contact (name and phone #) *

Medical Information

Current vet's name (or clinic name) and phone number *

I give Success Just Clicks permission to contact my vet in the context of behavioral training if necessary *

Yes

No

Date (or approximate) of last vet visit and any significant findings or reason for visit? *

Does your dog have any known medical issues? Is he/she currently on any medication (other than heartworm or flea/tick)? *

(like arthritis, loss of hearing, joint disorders, IBD, lyme disease, etc)

Date of last Rabies vaccine (or titer if medically exempt) *

All SJC clients are required to be up to date on their rabies or be medically exempt with or without a titer level. Please be prepared to have a copy of this during your initial lesson.

What is your dogs current diet? Is your dog free-fed or fed at specific meal times? How much are they fed per meal? *