The information you provide is important in diagnosing and treating your pet’s behavior problems. Please print this form and fill it out as completely and accurately as possible. If additional space is required, please attach a separate sheet.

General Information

Name Date of consultation

Address

Phone numbers: Home ( ) - Business ( ) -

Veterinarian/clinic

Referred by (if other than veterinarian)

How many people live in your household?

Ages of children?

Pet Information

Name

Breed

Weight Age Sex M/F

Neutered? Y/N Age neutered

Any change after neutering?

Where did you obtain this pet?


Is your pet declawed? Y/N Age at declawing

Behavior of parents or litter mates



Environment/Lifestyle
Why did you obtain your cat? (Companion, breeding, ect.)

Type of food

How often and when is pet fed?

Describe eating habits (e.g. picky, voracious)

List treats or supplements

How often are they given?

Favorite treat

Do you give catnip Y/N How often?

Does you cat hunt? Y/N What does your cat hunt?

What does cat do with prey after caught?

Amount/frequency of play

When is cat most interested in play?

Does the cat have a play center? Y/N Describe

List games/activities cat enjoys

Favorite toy

How long is the cat home alone on the average day?

Cat’s reaction to being alone

Is the cat ever allowed outdoors? Y/N Is the cat ever outdoors unsupervised? Y/N

How often and for how long?

Describe where the cat stays/sleeps at each of the following times

Daytime when owners are home

Daytime when owners are away

Nighttime

When quests visit

How does your cat react to the following situations?

Car rides

Loud noises

Strangers

New (non-family) cats

New (non-family) dogs

Other animals


Grooming, scratching, and Kneading
Describe your cat’s grooming.
Are there any situations that cause grooming to increase? Y/N
Describe

Does your cat have a scratching post? Y/N
Describe

Does your cat scratch any areas/objects other than its scratching post? Y/N

Describe locations and types of surfaces preferred

Does your cat knead? Y/N
Describe


Household Layout
Describe home, apartment, semidetached home, basement, ect.
How many stories?How many rooms?

On a separate page, please draw a simple diagram of each floor of your home.

Use the following keys to indicate the location of each of the following:

Kitty litter (use numbers 1, 2, 3 to correspond to box locations)
Feeding location - F
Play area - P
Scratching post - SP
Sleeping area (nighttime) - SN
Sleeping spots (daytime) - SD
Site of inappropriate scratching - D
Site of inappropriate elimination/ urine - U
Site of inappropriate elimination/ bowel movement - BM

Elimination & Litter Information
Does your cat use a litter box for stools? Y/N     urine? Y/N

What percentage of stool elimination is done outdoors?

What percentage of urine elimination is done outdoors?

Does your cat dig/bury after eliminating? Y/N

How often is the litter box cleaned/ changed?

Number of litter boxes?

What type of litter do you use?

Is scented or deodorized?

For each box, indicate location, type of litter, type of box
Litter box 1

Litter box 2

Litter box 3

List and other litters you have tried and cat’s reaction

List any other types of litter boxes you have tried and cat’s reaction

List any other litter box location you have tried and cat’s reaction

If you have more than one cat, do they have different litter boxes?

If yes, describe where each litter box is located

Do the cats use each other’s litter boxes? Y/N Comment

Family / Relations
List each family member (including sex and age)



How does your cat get along with each family member?



Who feeds? Who plays?

Who grooms? Who gives treats?

Briefly describe the family schedule, including how long left alone



List any other pets, including species, breed, age, and sex



How do each of the pets get along with each other?



Training
What commands does your cat respond to?

What rewards work best?

Describe your cat’s learning ability

Who does your cat respond to the best?

List any “tricks” your cat can perform


Handling
How does your cat react to each of the following?
Nail trimming

Giving medication

Cleaning/treating ears

Lifting/carrying

Patting/stoking

Bathing

Grooming/brushing

Punishment
How does your cat react to each of the following?
Physical

Noise(siren)

Ultrasonic (PetAgree???)

Water sprayer

Handling/Lifting

Verbal

Pinning

What punishment is most effective?

Describe any punishment that has had an adverse effect?



Does the cat respond differently to different family members?



Briefly describe your cat’s personality

I Hereby give permission to Centennial Animal Hospital to phone my Veterinarian’s clinic to verify my cat’s vaccination status (D H L L P - C, Rabies, Titers)

(Please Initial): ___________

Trainer reserves the right to refuse training any cat that is obviously sick or overtly aggressive. Trainer cannot guarantee each individual cat’s ability to learn and/or understand signals, commands, or cues. Trainer reserves the option to refer aggressing cats to other professionals in the field of Dog Training and Behavior.

Liability Release:

Owner agrees that Centennial Pet Boarding and Grooming and its Behaviour Staff and any referring organization and or other participants will not be liable for any damage or loss resulting from failure of the cat to respond to any signals, commands, or cues taught to the cat by Centennial Pet Boarding & Grooming and Behaviour Staff or resulting from counseling, instruction, or advice supplied to owner of cat.

Dog’s behavior now and in the future is solely the responsibility of the owner of the cat. Should any behavior on the cat’s part now or in the future result in damage to property, owner, or persons of some third party, owner agrees to assume full responsibility and liability to such third party for any and all such damage, and to absolve Centennial Pet Boarding & Grooming and its Behaviour Staff and any referring organization and or other participants from any and all obligations to pay such damage to some third party.

All cats are trained or otherwise handled or cared for by Centennial Pet Boarding & Grooming and its Behaviour Staff and any referring organization and other participants without any liability whatsoever on Centennial Pet Boarding & Grooming and its Behaviour Staff and any referring organization and or other participants for loss or damage from disease, death, running away, theft, fire, injury to persons, other cats, other animals, or property by said cat, or other unavoidable causes. Adults are responsible for their minors.

Refund policy: No refunds given unless Centennial Pet Boarding & Grooming and its Behaviour Staff permanently cancels classes and or lessons. No refund if owner misses or drops out of classes and or lessons. No pro-rates given for missed classes and or lessons.

I have read the above contract and liability release and agree to all terms and conditions:

Signature of Owner: _____________________________ Date: _______________________