Required answers in bold, gold text

First Name:
Last Name:
Address:
City:
State:
Zip:
Phone Number:
Best time to reach you at this number:
Email Address:
Which method do you preferred to be contacted:	Email Phone
Number of children in your home 0-6 years old:	0 1 2 3+
Number of children in your home 7-12 years old:	0 1 2 3+
Number of teenagers in your home:	0 1 2 3+
Number of adults in your home:	0 1 2 3+
Your dog's name:
Age of pet:	(example: 1 year, 12 weeks, etc)
Sex:	Male Female Neutered Male Spayed Female
Breed:	(use Mixed if unknown)
Approximate date of last vet visit:
Did you adopt this pet from the Franklin County Dog Shelter:	Yes No
If yes, date of adoption:
If no, where did you obtain this animal?:
Are you considering giving up your pet because of this behavior problem?:	Yes No
How did you here about this site?:	Word of Mouth Followed the links on this site Linked from another site Read about it in newspaper Seen it on T.V. (news) Heard about it on the radio
Source of reference to this site:	(i.e. name of site, tv channel, radio channel etc.)
Number of pets (other than the one specified above) do you have:	0 1 2 3+
Other pets currently in the home:	Type:	Dog Cat Other <-- If other Type
	Age:
	Breed:
	Sex:	Male Female Neutered Male Spayed Female
	Type:	Dog Cat Other <-- If other Type
	Age:
	Breed:
	Sex:	Male Female Neutered Male Spayed Female
	Type:	Dog Cat Other <-- If other Type
	Age:
	Breed:
	Sex:	Male Female Neutered Male Spayed Female
If you have more than 3 pets please enter additional relevant info in comment section
Briefly describe behavior problem (comments):
Please understand that advice relating to certain behavioral problems should not be given over the telephone or internet. Depending on the problem, a behavioral consultation may be neccessary. Would you be willing to schedule a consultation?	Yes No