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INTAKE FORM *This class is sponsored by PAWS*

We’d like to help your dog do great things, so we appreciate your time in helping us to get know him/her better. The following screening will take 10-12 minutes to complete. Please tell us more about your dog: Your name Dog’s name ___________________ Breed How long you have been together? How did you find each other?

Dog’s age Circle one: spayed neutered in-tact

Veterinarian Dog’s Health History (surgeries, injuries, current conditions): Please note: A copy of your dog’s current health records will be required the first night of class

1. Why do you think your dog would be a good visitor/ambassador? 2. Describe your dog’s personality and list any special talents/skills: 3. What places/programs are you interested in visiting? Any you especially DO NOT want to go? Why? 4. Previous Training/Certification: ___________________________________________________ Where? Dog’s age at time of training:

Before you continue, please read and accept our refund policy…. Refund Policy: A 50% non-refundable deposit is required to guarantee your spot in the class. Classes and evaluations that are cancelled at least 7 days prior to the date of the first class will be given a full refund or option to transfer to a later class. Cancellation less than 7 days prior will be given a 50% refund if the space can be filled or the option to transfer to a later class. Due to limited class size, there are no refunds or transfers once class begins. Have you read, and do you agree to the refund policy? I agree to the above stated refund policy: Signature:

Date:


“What Every Therapy Dog Should Learn” will help you fine tune rough edges and expose your dog to situations that will be like what you both will encounter on visits, but your dog should have basic obedience skills: be well socialized with other people, dogs and situations; and be well-mannered. Is your dog ready to be certified for animal visitation? Dogs are ready when they are reliable and respond well to their handler’s directions even in situations with distractions. The following quiz will help you evaluate your dog’s readiness. (By responding to these questions, you can help us understand at what level you and your pup are starting and how best to help you get to therapy dog level or whether other classes might be needed before you attempt certification.) Please put a number by the question that best reflects your dog’s current ability: (feel free to write on the back) 5 = Always 4 = Usually 4 = Sometimes 2 = Seldom 1 = Never My dog is… ____ 1. friendly with people (wags tail/enjoys petting; no barking, growling) of all ages/ethnic backgrounds. Comments:

____ 2. well-behaved with people (keeps all 4 paws on the ground/ no licking, sniffing, and or mouthing.) Comments:

____ 3. is friendly with other dogs/animals (wags his tail without barking, growling, snarling). Comments:

____ 4. is well behaved with other dogs/animals (keeps all four paws on the ground without barking, licking, sniffing, or “play-biting”; takes food politely). Comments:

____ 5. is calm in new and/or public places (walks loosely on leash; no straining/panting/barking/marking or peeing) Comments: Please list the places you currently take your dog.

____ 6. is calm with loud noises (looks but stays in place). Comments:

____ 7. waits at doorways. Comments:

____ 8. knows Sit, Down, Stay and Come (using whatever words you use): Comments:

___ 9. will respond to the above commands in situations with distractions (e.g. noise, other animals): Comments:

___ 10. will Stay in a Sit or Down position for ____ seconds with and without distractions. Comments:

___ 11. will let strangers handle him (petting, brushing, etc.) all over his body without struggling. Comments:

___ 12. will “Leave” food/toys/other dogs alone when given your command. Comments:

WHAT Class Screening Form  

WHAT Class Screening Form

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