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: 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 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
