Local Therapy Team Evaluation Form

Name

Birthdate

Addresss

City

State

Zip

Home Phone

Email Address

Name

Breed

Sex

Male Female

Age (Must be at least 1 year old)

Status

Intact Altered

Small Dog (15 lbs or lighter):

Yes No

Carried (arms/stroller)

Yes No

Lifestyle

Active Moderately Active Sedentary

Is animal boarded at kennels?

Yes No

How often?

What activities do you do with your animal that would expose it to other animals?

Dog/Cat shows State/County Fairs Other

Other

Does your animal spend time outdoors (other than for routine walks)?

Yes No

Other

How long have you had or known this animal? (Must be at least six months.)

Have you or your animal trained or practiced at the same location where you are being evaluated?

Yes No

Please explain

If you are registering with a dog, has the dog ever been encouraged or trained to bite, even as part of a dog sport (e.g.,Schutzhund)?

Yes No

List all commands this animal responds to reliably

Is there a specific age group that this animal avoids or seems uncomfortable around?

Yes No

Other

Is there a type of individual that this animal avoids or seems uncomfortable around?

Yes No

Check all that apply

Other

Has this animal ever acted in a threatening or menacing manner towards an individual or group of individuals? Threatening/menacing includes: overt staring, growling, snapping, snarling, barking at, lunging toward or biting an individual.

Yes No

Please describe

Other

How do you discipline/correct this animal?

What does this animal do when it becomes stressed?

What do you do when you recognize that your animal is stressed?

List any kinds of animals that this animal does not react to well:

Contact Board Member