Your name:
Your email address:
Your phone number:
Your Questions,
Comments, or
Feedback:
To Contact Us Via the Web:
Our Contact Information:
Email: solutions@repertoiretraining.com
Phone: 414-254-2059
Patricia McKenzie, MS, ABCDT, CPDT
Owner, Trainer, Member Manager
Email: patty@repertoiretraining.com
Phone: 414-254-2059
Repertoire Animal Training & Behavior, LLC
Serving Southeastern Wisconsin
Contact Repertoire
Behavior Modification Consultation Questionnaire:
**Please allow 30 to 40 minutes to complete the three sections of this questionnaire.**
The first two questions on this form are optional.  If you chose to answer them they will help Repertoire track its marketing efforts more efficiently.
1.
2.
Please take a moment to tell us how
you heard about Repertoire Animal
Training & Behavior, LLC:
If referred to us by a person, business, or other
please tell us specifically:
3. Family Demographics
Your Name*:
Occupation:
Home Phone:
 Cell Phone:
Work Phone:
 Email*:
Zip*:
Street Address*:
 City, State:*
Name of
Spouse/Partner:
Occupation:
List Adults in Household and
Their Relationships to You:
No. of People in Household*:
List Children in Household,
Their Ages, and Their
Relationship to You:
List Pets in Household, Their
Type/Breed, and Their Ages:
Total No. of Pets in Household*
4. Companion Animal Information
Female
Age:
 Male
 Breed:
Dog's Name*:
Spayed/Neutered?
 Yes
 Indoor
 Outdoor
 Both
No
Primarily indoor, outdoor, or both?
Where did you get your dog?
How long have you had your dog?
Briefly describe your dog's personality:
List any known prior history of your dog:
Describe the behavior issue that prompted you to
seek services.  If there are multiple issues please
list them in their order of importance to you:
End of Part I.  Please click submit to continue.
Dog Behavioral History Questionnaire Part I
The following questionnaire should be filled out by persons who have decided to take advantage of Repertoire's
behavior modification services for their family dog.  This is a three part questionnaire.  At the beginning of parts II & III you will
be asked to restate your dogs name.  If you do not wish to fill out this form, we will fill it out for you at the intake interview; however, we
feel it is to your advantage to complete it prior to the first consult.  Submitting this form ahead of time will save time at the intake
interview; thereby saving you money.  It also will help your Repertoire consultant be better prepared at the initial session.  

Still unsure if you should fill out this questionnaire?  For more information on our training and behavior modification services see  
What's the Process? What Can I Expect?,  or visit our Contact Us page to find out how to speak to a Repertoire representative.

Complete this form to the best of your ability.  Be as honest and detailed as possible.  Repertoire understands that dealing with
behavioral issues can be stressful and challenging.  Families who seek behavior modification services are often at a loss for how to
handle a particular behavioral problem and may have tried varied means of extinguishing the behavior, or they may have given up
altogether.  Repertoire wants to help.  The answers you provide here will help us more clearly identify the specific issue and they will
become the basis for an individualized training / behavior modification plan to suit your needs.
Repertoire Animal Training & Behavior, LLC   Copyright 2007