Please take your time filling out this form. The more detail the better. You can expect to take 20-30 minutes to fill out the form–there are several pages to fill out.

Do not uses your browser’s back/forward button, your responses will be lost and you’ll start over.

Also, in the event of a tech issue, we HIGHLY recommend copying your open-ended answers and pasting them into an email or a document so if you happen to lose your responses, you can easily go back through the form and won’t need to re-type all the open ended answers.

Behavior Modification History Form

Specifically for dogs who are struggling with behavior problems like reactivity, aggression, resource guarding, phobias, anxiety, separation struggles, obsessive behaviors, and similar.

New Client Application--Behavior Modification

Basic Information

Basic Contact Information

Name(s) *

Dog Name(s) *

Address (street) *

Address (City and Zip Code) *

Any special parking instructions or directions that GPS will miss? *

Email Address(es) *

Phone Number(s) *

Please note your preferred phone number

How did you hear about us? *

Emergency Contact (name and phone #) *

Current vet's name (or clinic name) and phone number *

I give Success Just Clicks permission to contact my vet in the context of behavioral training if necessary *

Yes

No

Basic Information--Human and Canine

If you’ve had dogs before, tell me about them and your experiences: *

Tell me a little bit about your dog(s)’s personality: *

What's your favorite thing about your dog(s)? *

Please list ALL members of your household with ages of any children (and any very frequent visitors) *

What type of exercise does your pup(s) get? How often do they get that exercise? *

If you are human, leave this field blank.

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successjustclicks@gmail.com

1932 Spring Garden Ave
Pittsburgh, PA 15212

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