Pets In Crisis Other Pet 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: About Your Pet Name: * Type of animal * Breed: * Age: * Sex: * Female Male Weight (kg) * If you don't know, please estimate Colour: * Usual vet clinic: * Date of last vaccination: * Who is currently caring for your pet, and where are they located? * Where did you obtain your pet? How long have you had your pet for? If your pet requires a licence to keep, do you hold the appropriate license? * e.g. Rainbow Lorikeet If your pet has any medical conditions, please detail below: * e.g. itchy skin, allergies, ear infection, sensitive tummy, etc. If your pet 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? * What sort of housing do you keep your pet in? * How often do you interact with your pet? * Are there any other animals in the house? If so, how do they interact with each other? * Please list anything your cat is scared of: * E.g. loud noises, thunderstorms, fireworks, etc. Are there any behaviour concerns we should be aware of? If yes, please detail below. * Diet & Feeding What type of food does your pet eat? * Please include brand names What quantity and how often do you feed your pet? * e.g. one cup twice a day Additional Comments Is there anything else you'd like us to know about your pet? Submit
