Adoption – About You Form Adoption - About You Step 1 of 13 7% Please start by telling us your basic information: Your Name(Required) First Last What is your approximate age group? e.g. 40sAddress(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneMobile(Required)Preferred Email(Required) Other adults who spend significant time with your dog(s) This section is for you tell us about ALL ADULTS who live in your house but also about any other friends or family who spend significant regular time with your dog Adults who live at home with you: How many other adults live at home with you?(Required) Adult 1: Name First Last Approximate age group e.g. 40sRelationship to you e.g. partner, daughter, step-son, lodgerWould you like this person to be in your Client WhatsApp Group? Yes No Mobile(Required)Would you like this person to be included in emails? Yes No Email(Required) Adult 2: Name First Last Approximate age group e.g. 40sRelationship to you e.g. partner, daughter, step-son, lodgerWould you like this person to be in your Client WhatsApp Group? Yes No Mobile(Required)Would you like this person to be included in emails? Yes No Email(Required) Adult 3: Name First Last Approximate age group e.g. 40sRelationship to you e.g. partner, daughter, step-son, lodgerWould you like this person to be in your Client WhatsApp Group? Yes No Mobile(Required)Would you like this person to be included in emails? Yes No Email(Required) Adult 4: Name First Last Approximate age group e.g. 40sRelationship to you e.g. partner, daughter, step-son, lodgerWould you like this person to be in your Client WhatsApp Group? Yes No Mobile(Required)Would you like this person to be included in emails? Yes No Email(Required) Details for other adults at home: If you live with more than 4 other adults, please tell us about the others here:NameApproximate age groupRelationship to you Add Removehandy hint.... click the + on the right hand side to add more rows!Please put any other relevant information about these people here: Any other adults who do not live with you: Please tell us about any other adults (not living with you) that your dog spends significant time with?NameApproximate age groupRelationship to youHow often do they see your dog(s)? Add RemoveE.g. parents or partners living at another address. Please do not include professionals like dog walkers in this section. And a handy hint.... click the + on the right hand side to add more rows! Please put any other information you wish to provide about these people here: Children who spend significant time with your dog(s) Children who live at home with you: How many CHILDREN UNDER 18 live at home with you?(Required)If none, please enter 0Please give details of ALL children who live at home here:NameAgeRelationship to you Add RemoveHandy hint.... click the + on the right hand side to add more rows!If there is anything else that it would be helpful for us to know about children living at home, please pop this information here:If this is an assessment for a child who is not currently living with you and is not mentioned above, please tell us as much as you can about the child who will be coming to live with you here; Any other children who do not live with you: Please tell us about any other children (not living with you) that your dog spends significant time with?NameApproximate age groupRelationship to youHow often do they see your dog(s)? Add RemoveHandy hint.... click the + on the right hand side to add more rows!If there is anything that it would be helpful for us to know about these children, please pop this information here: Medical issues it would help us to be aware of It is really helpful for us to know if you, or anyone at home, has any medical conditions that may affect how you interact with your dog or how you may wish to work with us. We will make every effort to put adjustments in place wherever we can - our aim is for life with your dog to be as easy and enjoyable as possible and in particular, please let us know if there is anything we can do to make sessions more comfortable for you. Please tell us how you are affected and how we can best help (or put 'for info' if it is just so we are aware)WhoCondition or things you may find harderHow can we support you? Add RemoveFor example arthritis, restricted mobility, anxiety, reduced hearing or sight. Handy hint.... click the + on the right hand side to add more rows! Your routine and times you're out of the house Everyone's routine is different, having an understanding of your routine can be really important in helping us to provide the best support we can. We understand that routines can vary, so just put what your most average week looks like, we understand that this may look different from time to time! The more detail you can give, the better! What are your occupations and typical work hours? Please include travel time.(Required)Please tell us a bit about your general daily routine and make a note of any regular activities which mayimpact what you do with your dog e.g. going shopping or to the gym, activities you do regularly with your children, hobbies, caring for relatives etc.(Required)In one day, during the day, what is the AVERAGE amount of time your dog(s) is alone for?(Required) How many times a week is your dog alone for the AVERAGE time mentioned in the previous question?(Required) In one day, during the day, what is the MAX amount of time your dog(s) is alone for?(Required) How often is your dog alone for the 'MAX' time, mentioned in the previous question?(Required) e.g. twice a week, three times a month etc. Your house Just a brief description of the environment would be great! What sort of home do you have? e.g. detached/terraced/second floor flatWhere does your dog spend most of their time (during the day and overnight?) Is there anywhere your dog isn't allowed to go or which is by invite only? e.g. upstairs, on furniture etcWhat sort of area do you live in? e.g. rural/city centre/quiet cul-de-sac/by a busy main roadPlease describe your outdoor space if you have one e.g. large garden, mix of patio, grass and flower beds, small paved courtyard Your previous dog experience If you've had dogs before, tell us a little about them ... from puppy/rescue, what you most liked/enjoyed, what you found hard and how you managed this Your current dogs How many dogs do you have?(Required)Dog 1 name(Required) Dog 1 breed(Required) Dog 1 age(Required)Dog 1 Gender & Neuter Status Male - Entire Male - Neutered (castration) Male - Neutered (chemical) Female - Entire Female - Neutered Dog 2 name Dog 2 breed Dog 2 ageDog 2 Gender & Neuter Status Male - Entire Male - Neutered (castration) Male - Neutered (chemical) Female - Entire Female - Neutered Dog 3 name Dog 3 breed Dog 3 ageDog 3 Gender & Neuter Status Male - Entire Male - Neutered (castration) Male - Neutered (chemical) Female - Entire Female - Neutered Dog 4 name Dog 4 breed Dog 4 ageDog 4 Gender & Neuter Status Male - Entire Male - Neutered (castration) Male - Neutered (chemical) Female - Entire Female - Neutered Dog 5 name Dog 5 breed Dog 5 ageDog 5 Gender & Neuter Status Male - Entire Male - Neutered (castration) Male - Neutered (chemical) Female - Entire Female - Neutered More than 5 dogs? Tell us details of the others here.Please tell us a bit about how the dogs get on with each other. Focus on the relationships between the dogs, not any individual difficulties they have (like reactivity to other dogs outside - we'll get to this later!)How would you describe their general relationship(s)?Do they sleep together or separately? How often and in what sort of contexts?Do they play together? What sort of games? Who initiates and who ends the play?Is there any stress or conflict over food? E.g. worrying about the other dog approaching, eating faster, guarding food etc. Please describeIs there any stress or conflict over toys? Please describeIs there any stress or conflict over spaces (e.g. beds, sofas, rooms, doorways). Please describeIs there any stress or conflict over people (e.g. pushing in when the other dog gets attention). Please describeHow do the dogs behave when separated from each other (e.g. in different rooms, or if you take one out and not the other)Has there been any aggression or fights between the dogs at home?(Required) Yes No Please list these in chronological order if possible ...Incident 1 approx date DD slash MM slash YYYY Which dogs (if more than 2 at home) What happened?e.g. did it involve food/toys/people, at home or on a walk, were the dogs quiet/excited, who started itHow did you manage it at the time?Did they just stop? Did you have to split them up? If so, how.What were the injuries (if any) - to the dogs or to youHow were the dogs with each other immediately after and in the following few days? How did you reintroduce them if neededHas there been a second incident? Yes No Incident 2 approx date DD slash MM slash YYYY Which dogs (if more than 2 at home) What happened?e.g. did it involve food/toys/people, at home or on a walk, were the dogs quiet/excited, who started itHow did you manage it at the time?Did they just stop? Did you have to split them up? If so, how.What were the injuries (if any) - to the dogs or to youHow were the dogs with each other immediately after and in the following few days? How did you reintroduce them if neededHas there been a third incident? Yes No Incident 3 approx date DD slash MM slash YYYY Which dogs (if more than 2 at home) What happened?e.g. did it involve food/toys/people, at home or on a walk, were the dogs quiet/excited, who started itHow did you manage it at the time?Did they just stop? Did you have to split them up? If so, how.What were the injuries (if any) - to the dogs or to youHow were the dogs with each other immediately after and in the following few days? How did you reintroduce them if neededHas there been a fourth incident? Yes No Incident 4 approx date DD slash MM slash YYYY Which dogs (if more than 2 at home) What happened?e.g. did it involve food/toys/people, at home or on a walk, were the dogs quiet/excited, who started itHow did you manage it at the time?Did they just stop? Did you have to split them up? If so, how.What were the injuries (if any) - to the dogs or to youHow were the dogs with each other immediately after and in the following few days? How did you reintroduce them if neededHas there been a fifth incident? Yes No Incident 5 approx date DD slash MM slash YYYY Which dogs (if more than 2 at home) What happened?e.g. did it involve food/toys/people, at home or on a walk, were the dogs quiet/excited, who started itHow did you manage it at the time?Did they just stop? Did you have to split them up? If so, how.What were the injuries (if any) - to the dogs or to youHow were the dogs with each other immediately after and in the following few days? How did you reintroduce them if neededHave there been any more incidents? Yes No Please describe any other incidents here Other Animals Do you have any other animals in the house?(Required) No other animals in the house Cats Rabbits Other If other, please specify; Do you have any other animals in the garden or somewhere your dog goes regularly e.g. smallholding/stables?(Required) no other animals cats rabbits (pet, not wild!) horse sheep cattle chickens/ducks/geese other If other, please specify; What sort of contact (if any) does your dog(s) have with each animal and how do they get on?do they ignore each other, enjoy playtime, sleep together, does one dislike or is fearful of the other?Any concerns about how they interact?e.g. dog trying to herd fish in tank, chasing chickens etc Is there anything you would like support with? Whilst this is an assessment process, we’re actually here to help identify what support you might need to make this work, as far as possible that is always our goal! So if there are any things that you think it would help you to have a bit of advice on, anything that you think might help your dogs or that you are worried about, please let us know here and we can give you support for those as a part of the assessment.(Required) Your Vet Please don't forget to complete the separate authorisation form for us to speak directly with your vet.Name of main vet practice(Required) Name of vet you usually see Do you use any other vet practices or professionals (e.g. veterinary physiotherapist). Please give us details here. Significant changes in the last 6-12 months in chronological order please! In the time you have had your current dogs, please tell us about any major events or changes (with rough dates so we have a timeline!) e.g. moving house, major renovations, new job, new partner, new baby, new pets, major holidays, illness etc.Change 1 Dates e.g. Jan 2019 to Mar 2019Brief description of any impact on the dogs/changes you noticed in behaviour etc.Want to add a second change? Yes No Change 2 Dates e.g. Jan 2019 to Mar 2019Brief description of any impact on the dogs/changes you noticed in behaviour etc.Want to add a third change? Yes No Change 3 e.g. Jan 2019 to Mar 2019Dates Brief description of any impact on the dogs/changes you noticed in behaviour etc.Want to add a fourth change? Yes No Change 4 Date e.g. Jan 2019 to Mar 2019Brief description of any impact on the dogs/changes you noticed in behaviour etc.Want to add a fifth change? Yes No Change 5 Date e.g. Jan 2019 to Mar 2019Brief description of any impact on the dogs/changes you noticed in behaviour etc.Want to add a sixth change? Yes No Change 6 Date e.g. Jan 2019 to Mar 2019Brief description of any impact on the dogs/changes you noticed in behaviour etc.Anything else? Yes No Please list anything else hereAnd then going forwards ...Are there any significant planned events in the next 6-12 months?e.g. moving house, major renovations, new job, holidays, new baby etc. And that's it! Time to submit..... 14492
