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Enter your Name and Address details below. (Fields with * need completion for form to submit)
First Name

Last Name

Email Address*

Work Phone

Home Phone

Mobile

Fax

Address

Address 2

Address 3

Suburb*

State*

Zip Code*

Country*

Your Lifestyle: Your lifestyle is shared by your pets and vice versa. Obtaining information about this helps to make tailored behaviour solutions that work.
No. Infants (under 5 yrs) at home? Unknown 0 1 2 3 >3

No. Children (5-15 years) at home? Unknown 0 1 2 3 >3


No. Adults (15-60ys) at home?
Unknown 0 1 2 3 >3


No. Seniors (over 60 yrs) at home?
Unknown 0 1 2 3 >3


What is your family's work routine?
Unknown
Mostly home
Variable attendance (shifts)
Mostly 20 - 40 hours away
Mostly 40 - 60 hours away


Pet's lifestyle when you are home
Unknown
House confined
Mostly an inside pet
An inside and outside pet
Mostly an outside pet
Entirely an outside pet


Pet's lifestyle when you are NOT home
Unknown
House confined
Mostly an inside pet
An inside and outside pet
Mostly an outside pet
Entirely an outside pet

Your Pet's Details:- Please complete the following details about your pet(s). If you have more than one pet, give the details of the pet with the biggest problem first. Then add similar details for your other pet(s) in the field provided
Pet Name


Pet Breed


Pet Sex
Unknown
Male desexed
Male entire
Female desexed
Female entire

Pet Birth Date (approx)

Age of pet when obtained Unknown
< 6 weeks
Btw 6 and 12 weeks
Btw 12 and 6 months
Btw 6 and 12 months
Btw 12 months and 2 years
After two years of age

What behaviour do you want to solve? Aggression to family
Aggression to visitors
Aggression to people met when out
Aggression to other dogs I own
Aggression to dogs met when out
Aggression to cats, livestock, wildlife
Barking when I am home
Barking when I am away
Boisterous and disobedient
Destructive, chewing, digging

  House-soiling
Pacing, spinning, tail-chasing
Escaping and roaming
Noise phobias
Separation anxiety
Fearful, timid, generally anxious
Attention seeking
Eating unusual objects
Problem not listed

Please do this bit! Add details of other pets and fully describe your concern here

This field needs a response to allow form submission. If you indicate you need a consultation service we will contact you. If you select web membership, you have the option of asking for assistance or not. If you prefer the free DIY system we are unlikely to contact you due to the number of requests we receive. Thanks for your understanding!
What form of assistance would you prefer?* Full Therapy House call
Full Therapy Clinic Visit
Clinic Assessment
Tele-Assist Service
Web Membership DIY - and please contact me
..by phone
..by email
..by SMS
Web Membership DIY - but I don't need to be contacted
Free DIY - I don't need to be contacted.

Please enter how you find us. If you were referred by a vet or pet care professional please enter details here
Who referred you to us?
Click the submit button - you should then proceed to a Thank You page. If nothing appears to happen, scroll through the form to ensure all fields marked with * are completed. If successful, you should get an immediate automatic reply by email.
 
* Indicates field is required.