Pets In Crisis Cat Intake Questionnaire About You Who are you completing this form for? * Myself I am a Case Worker completing this form on behalf of a client OtherOther Your name: * Safe number: * Safe email: * Do you currently have a fixed address? * Yes No If yes, please provide your safe address below: Which suburb do you currently reside in? * Alternate contact's name: Alternate contact's number: Case worker’s name: Case worker’s number: Case worker’s email: If you are self-referring, please note that a case worker will need to be assigned for us to liaise with before your pet(s) can be fully accepted into the Pets in Crisis program. Yes No About Your Cat Name: * Breed: * Age: * Sex: * Female Male Weight (kg) If you don't know, please estimate Colour: * Date of last vaccination: * Microchip number (if known): * Are they sterilised? * Yes No Unsure If your cat is female and unsterilised, when was she last in season? Who is currently caring for your cat, and where are they located? * Where did you obtain your cat? How long have you had your cat for? If your cat has any medical conditions, please detail below: * e.g. itchy skin, allergies, ear infection, sensitive tummy, etc. If your cat is receiving any medical treatments or medication, please detail below: The Home Environment What kind of living situation do you usually have? * Apartment/flatTown houseHouse with small yardHouse with large yardFarmI am currently staying with friends/ family Do you have children in your household? If so, how old are they? * On a daily basis, what percentage of time does your cat spend indoors vs outdoors? * Does your cat use a litter tray? * Yes No On average, how many hours per day is your cat left alone? * Where does your cat spend most of their time when left alone? * Where does your cat sleep at night? Is your cat around other animals? If yes, what kind of animals, and how do they interact? * What things does your cat like or enjoy? * e.g. being tickled under the chin, etc. What things does your cat NOT like or enjoy? * e.g. being touched on the ears, etc. Please list anything your cat is scared of: * E.g. loud noises, thunderstorms, fireworks, etc. Are there any other behaviour concerns we should be aware of? * Additional comments Is there anything else you'd like us to know about your cat? Submit
