Initial Client Consult Questionnaire

Veterinary Communication Form Template

Dear Dr. (Veterinarian’s Name),

At the request of (Client’s Name), I am treating (Dog’s Name) for (Behavior Issue.)
As a professional courtesy and with the client’s permission, this form outlines my behavioral assessment and treatment plan for your records. Should you have any questions or might I be of any assistance please do not hesitate to contact me. Perhaps there is an opportunity to work together and share information that may be of benefit to (Dog’s Name’s) physical and behavioral health.
Sincerely,
Trainer’s Name, Trainer’s Credentials, Business Name
Trainer’s Contact Information
Behavioral Issue:
State the official assessment and provide any background information of explanation you believe would be helpful.
Behavioral Prognosis:
State your assessment of the likelihood and level of improvement that might be expected with consistent adherence to the behavioral treatment plan, as well as any other variables that are at play. This might include the vet’s own participation as well.
Treatment Plan Overview:
Share an overview of your treatment plan. Rather than step-by-step explanations, outline the basic premise and approach you are taking and why, as well as any theoretical background that might be helpful.
Specific Training Protocols of Note:
Here you might share more detail about any portion of the plan that the vet and/or his/her staff might play a role in. If you are hoping that they will help to follow part of your plan, this is where you can explain that part in detail.

Again, please do not hesitate to call should you have questions or if I might be of assistance.

(Trainer’s Signature, Trainer’s Title/Business Name)Date

Dear Dr.

At the request of , I am treating for.
As a professional courtesy and with the client’s permission, this form outlines my behavioral assessment and treatment plan for your records. Should you have any questions or might I be of any assistance please do not hesitate to contact me. Perhaps there is an opportunity to work together and share information that may be of benefit to physical and behavioral health.
Sincerely,
Behavioral Issue:
Behavioral Prognosis:
Treatment Plan Overview:
Specific Training Protocols of Note:

Again, please do not hesitate to call should you have questions or if I might be of assistance.

TrainerDate

Dear Dr. Martins,

At the request of Marie Jones, I am treating Fido for leash reactivity.
As a professional courtesy and with the client’s permission, this form outlines my behavioral assessment and treatment plan for your records. Should you have any questions or might I be of any assistance please do not hesitate to contact me. Perhaps there is an opportunity to work together and share information that may be of benefit to Fido’s physical and behavioral health.
Sincerely,
Lisa Smith, CPDT, Good Dog Training

123.456.7890
Behavioral Issue:
Fido is displaying lunging and barking behavior at other dogs while on leash at distances of 25 feet and closer. The behavior appears to be leash-based barrier frustration that has increased in intensity over a period of two years.
Behavioral Prognosis:
Because Fido shows some positive interest in dogs at a distance, and because she does have one or two dog friends, the prognosis is favorable that she should be able to learn to see, pass, and encounter other dogs on leash for short durations of time. In short, she should be able to learn to walk on leash without incident.
Treatment Plan Overview:
The focus of the training plan is to change Fido’s emotional response to other dogs. Fido will learn the cue “Watch” as a low-level DRI behavior to replace her current behavior of lunging and barking. We will simultaneously use Desensitization and Counter Conditioning procedures. Once the Watch is in place Fido will learn to walk parallel to other dogs, gradually reducing the distance between them. We’ll then graduate to short, controlled on-leash greetings.
Specific Training Protocols of Note:
It is helpful for Fido not to be surprised by other dogs in close proximity. Anything your staff can do to help navigate Fido and her family through the office without seeing other dogs can help immensely.

Again, please do not hesitate to call should you have questions or if I might be of assistance.

(Trainer’s Signature, Trainer’s Title/Business Name)Date