Clickstart’s
Intake Form

Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

The above DOB is exact.

The above DOB is an estimate

Dog's Sex *

Male (neutered)

Male (in tact)

Female (spayed)

Female (in tact)

When was your dog's last wellness check with a veterinarian? *

MM

DD

YYYY

My dog is up-to-date on their:

Select all that apply

Canine Influenza

Heartworm Prevention

Flea & Tick Medication

Bordetella

Required Vaccines (Rabies & DHPP)

When was dog obtained? *

MM

DD

YYYY

Equipment currently used on walks? *

Select all that apply

Head Halter (Gentle Leader, etc.)

Shock Collar (e-collar, etc.)

Choke Chain (or slip lead)

Prong Collar

Harness

Regular Flat Collar

Equipment previously used on walks? *

Select all that apply

Regular Flat Collar

Harness

Prong Collar

Choke Chain (or slip lead)

Shock Collar (e-collar, etc.)

Head Halter (Gentle Leader)

Service(s) you're most interested in: *

Select all that apply. Please note: Reactivity and Aggression cases are often started virtually on Zoom.

Private Coaching (dog, guardian & trainer)

Group Classes (on-campus in Lake Forest)

Virtual Private Coaching (LIVE on Zoom)

Self-Paced: eBooks, eCourses & Patreon Subscription

Reactivity Training (barking at dogs, people, or other stimuli)

Other

Alternate Contact Name

Partner or other family member who wants to be included on wrap up materials or contacted if primary guardian cannot be reached.

First Name

Last Name

Alternate Contact Phone

(###)

###

####