About You
Your name:
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Safe number:
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Safe email:
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If yes, please provide your safe address below:
Which suburb do you currently reside in?
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Alternate contact's name:
Alternate contact's number:
Case worker’s name:
Case worker’s number:
Case worker’s email:
About Your Dog
Name:
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Breed:
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Age:
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Weight (kg)
Colour:
Date of last vaccination:
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Microchip number (if known):
If your dog is female and unsterilised, when was she last in season?
Usual vet clinic:
Who is currently caring for your pet, and where are they located?
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Where did you obtain your dog?
What age was your dog when you acquired them?
If your dog is receiving any medical treatments or medication, please detail below:
The Home Environment
What kind of living situation do you usually have?
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Apartment/flat Town house House with small yard House with large yard Farm I am currently staying with friends/ family
Do you have children in your household? If so, how old are they?
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On a daily basis, what percentage of time does your dog spend indoors vs outdoors?
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On average, how many hours per day is your dog left alone?
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Where does your dog spend most of their time when left alone?
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Where does your dog sleep at night?
How often is your dog walked, and for how long?
How does your dog behave around strangers?
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Where is your dog kept when you have guests?
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Has your dog ever bitten a person? If yes, please give details:
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Has your dog ever been in a fight? If yes, please give details:
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How often is your dog around other dogs?
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How does your dog interact with other dogs?
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Are there any other behaviour concerns we should be aware of?
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Training
Additional comments
Is there anything else you'd like us to know about your dog?
If you are human, leave this field blank.
