Separation Anxiety Questionnaire Please complete this questionnaire for your dog and we will be in touch to schedule a phone call. If your dog is suffering from separation anxiety and you would like us to consider working with you, please take the time to fill out the following questionnaire. Filling out this questionnaire does not guarantee that we will be able to accept you as a client. We look forward to assessing your case and seeing if we can assist you! Thank you. Client(s) Name*Email* Enter Email Confirm Email Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dog's Name*Dog's Gender*Intact FemaleSpayed FemaleIntact MaleNeutered MaleAge of Dog*Where dog was acquired? (Shelter/Breeder/Other)*Breed or Breed Mix*How long has your dog been in your household?*How often is your dog being left alone currently?*Can you adjust your schedule so that your dog will not have to be left alone during training for a while?*Have you done any previous training to address your dog's separation anxiety? If yes, please explain.*How long would you like to be able to leave your dog alone in the future? Please specify in hour range such as 2-4.*People living in your home (please note adult or child)*Do you have other pets at home? If so, please give species, gender and age.*What are the best days/times to schedule a free 30 minute phone call?*Please let us know how you heard of us.*CAPTCHACommentsThis field is for validation purposes and should be left unchanged.