INTAKE QUESTIONNAIRE

Date

Name*

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Cell Phone*

Home Phone

Work Phone

Which number is best for us to call, and is daytime or evening preferred?*

Email*

Alternate Email

Name of Weim*

Is your dog a Purebred Weim?*

Yes
No

AKC Registered?*

Yes
No

Where did you get your Weim and how long have you had him/her?*

What is the age and birthdate of your Weim?*

What is the gender of your Weim?*

Male
Female

Is your Weim spayed or neutered?*

Spayed
Neutered
Not fixed

Has your Weim ever been used for breeding?*

Yes
No

How much does your Weim weigh?*

What color is your Weim?*

Gray
Blue
Longhaired Gray
Longhaired Blue

Is your Weim's tail docked?*

Yes
No

Is your Weim Microchipped?*

Yes
No
Don't know

If your Weim is Microchipped, what is the name of the company and chip#

Vet or Clinic Name*

Please contact your vet’s office to let them know we may be taking your Weim into rescue, and to please release information about the Weim to us if we call. Also ask them to fax your Weim's records to us at 812-256-0249 or email them to intake@louisvilleweimrescue.com.

Name of Vet

Address of Vet Clinic

Street Address City State / Province / Region ZIP / Postal Code

Phone # of Vet

Heartworm Information*

On Monthly HW prevention (Yes, No)	Date of last test	Brand of monthly HW prevention	Last date given

Is your Weim current on his/her Rabies shot?*

Yes
No
Don't know

Is your Weim current on his/her Distemper shot?*

Yes
No
Don't know

Please describe any health issues.*

This does not prevent us taking your Weim, but helps us find the best foster/home for him/her.

What brand of food do you feed your Weim, how much and how often?*

Is your Weim house trained?

Yes
No

Is your Weim crate trained?*

Yes
No

If crate trained, how long is he left and where?

Separation Anxiety- Please describe if your dog has separation anxiety and how you handle it.*

Is your Weim destructive when you leave? Does your Weim escape his crate or injure himself trying? Does he drool, howl or bark when you are gone? Is he on any medication for this?

Does your Weim have any issues with resource guarding their food, toys, people?*

Yes
No

If your Weim guards resources, please explain circumstances.

Does he/she growl at other dogs who come near his/her toys or food? Does he/she growl if someone comes between you and him/her? Does he/she growl or snap if you take food away from him/her?

Is your Weim dog friendly?*

Yes
No

Describe where your Weim has met other dogs and how he has acted.*

Dog Park? Neighbor dogs? On walks? Parent's house? etc.

Is your Weim cat friendly?*

Yes
No
No cat

Describe your Weim's experiences with cats.

Lives with them? Visits homes with cats? Loves them or chases them, or attacks them?

Is your Weim housed with other pets?*

Please list all pets currently in your household, and if your Weim gets along with them. Please click on the question mark to the right to add another row. If you have a mobile device, the box to add more rows may appear under the rows. This helps us determine if your Weim has lived with animals and how they got along.

Pet Name	Type of Pet (Dog, Cat, etc.)	Breed/Weight	Gender/Age	Spayed or neutered?	Does your Weim get along with them?

What would you consider the level of prey drive in your Weim?*

Low - he barely notices other critters
Medium - he has a healthy interest in chasing squirrels, raccoons, chipmunks, birds etc.
High – nothing is safe; he will chase cats and other creatures at any cost.

Has your dog ever shown any animal aggression?*

Yes
No

Please describe the circumstances if he/she has shown animal aggression.

Is your Weim good around men?*

Yes
No

Is your Weim good around women?*

Yes
No

Is your Weim good around kids?*

Yes
No

Describe how your Weim acts around strangers.*

Slow to warm up? Barks and jumps? Hates strangers?

Members of your household - Please include yourself.*

Please list everyone living in your home (including yourself), their relationship to you, and their ages. Please click on the question mark to the right to add another row. If you have a mobile device, the box to add more rows may appear under the rows. This helps us determine if your Weim has lived with many folks and their ages.

Name	Relationship	Age

Describe your normal household activity level.*

Quiet
Moderate
Very Active
Chaotic

If your weim is not housed with children, please describe if he/she has been around children and their ages.*

Has your Weim ever shown any aggression toward people?*

Yes
No

Please describe the circumstances if he/she has shown any aggression toward people.

Does your Weim have a bite record?*

Yes
No

Please describe the circumstances of the bite.

Do you have a fenced yard?*

Yes
No

Describe Fence

Please describe the type of fence you have. Is it an electric fence? Does it surround a fully enclosed area? How high is it? What is it made of? Does he ever try to go over it or under it? This helps us determine if your Weims foster/forever home should have a fence.

Where does your dog go potty?*

Please check all that apply.

Fenced yard
Walk on Leash
Free Roam
Doggie door

On average, how many hours Is your Weim left alone each day? Where is he housed during this time? Is he in a crate or have free roam of the house, etc.? How long is the longest left alone?*

What commands does your Weim know?*

Sit
Down
Come
Shake Paw
Fetch
No commands

How is your Weim on the leash?*

Walks nicely
Pulls some
Drags me down the street

Does your Weim like to ride in the car?*

Does he ride nicely, bark, pace, get sick etc?

What activities does your Weim enjoy?*

Running, cuddling, swimming, fetch, chewing bones, etc.

What is a typical day for your dog?*

Explain any activities you do with him or if he just lays around all day. What time does he get up and go to bed, what time does he get fed? Do you walk him each day? Play with him? No exercise as you are not home often?

Are you willing to help transport your Weim? If you have a maximum driving distance, please note it.*

Our foster homes are located throughout Kentucky, Indiana, and Ohio. We have volunteers that help transport, but we like the owner to drive the first leg, which is usually about 1 hour to the meeting place.

Have you contacted any other rescues about your Weim?*

We work with other Weim rescues in surrounding areas. If you have already contacted one of them, please let us know. We are volunteers, and the work is duplicated if more than one rescue is contacted.

Yes
No

If you have contacted another rescue, please note which one.

What is your reason for wanting to rehome your Weim?*

Additional comments

Please upload a picture of your Weim.

Your Name*

Typing in your name here is your electronic signature that you are the one completing this form, that you are the owner of the Weim, and that all information herein is correct. You will be contacted within the next 24-36 hours to discuss your situation, answer any questions you may have, and talk about your Weim coming into rescue. If submit this form and get error messages, please review the form for completeness. Many fields are required and you may have missed entering some information.

Date Completed*

“Your intake application has been submitted successfully.”

SURRENDER-INTAKE