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Initial Assessment Questionnaire

Agreement

I UNDERSTAND THAT I WILL BE REQUIRED TO STOP USING ANY AND ALL AVERSIVE METHODS DURING BEHAVIOR MODIFICATION AND THAT IT IS STRONGLY RECOMMENDED THAT I CEASE THE USE OF THESE METHODS FOR THE REMAINDER OF THE LIFE OF THE ANIMAL(S).

CLIENT/OWNER ACKNOWLEDGES BY SIGNING THAT THEY HAVE CONSULTED WITH AND OR RECEIVED THE NECESSARY VETERINARY CARE PRIOR TO PARTICIPATING IN A BEHAVIOR MODIFICATION PROGRAM AND IS UP-TO-DATE ON RABIES AND DHLPP VACCINATIONS.  CLIENT/OWNER UNDERSTANDS THAT A COPY OF THE BEHAVIOR PLAN WILL BE SHARED WITH VETERINARIAN LISTED ABOVE FOR THE PURPOSE OF COORDINATION OF CARE AND HEREBY GIVES PERMISSION TO CAROLYN KOCMAN TO DO SO.

CLIENT/OWNER CERTIFIES THAT THEY UNDERSTAND THAT BEHAVIOR TECHNIQUES RECOMMENDED BY CAROLYN KOCMAN, PET BEHAVIOR SPECIALIST, LLC (AND ITS REPRESENTATIVES) COULD INVOLVE RISK TO PETS AND/OR HANDLERS, DESPITE ATTEMPTS TO MINIMIZE SUCH RISK. CLIENT/OWNER AGREES TO USE THEIR OWN JUDGMENT AND COMMON SENSE WHEN FOLLOWING RECOMMENDATIONS IN ORDER TO AVOID UNDUE RISK OF ANY KIND.  

CLIENT/OWNER UNDERSTANDS THAT PAYMENT IS TO BE MADE IN FULL AT LEAST 48 HOURS IN ADVANCE OF ANY APPOINTMENT. FAILURE TO DO SO WILL RESULT IN THE APPOINTMENT BEING CANCELED. CLIENT UNDERSTANDS THAT THERE IS A $50 NO-SHOW/LATE CANCEL (WITHIN 48 HOURS) FEE WHICH WILL BE CHARGED TO THE CLIENT. CLIENT/OWNER AGREES TO PAY SAID FEE, SHOULD THE CLIENT NO-SHOW OR CANCEL WITHIN 48 HOURS OF THE APPOINTMENT. CLIENT WILL NOT RECEIVE ADDITIONAL SERVICES FROM BEHAVIOR PROFESSIONAL UNTIL SAID FEE IS PAID.

CLIENT IS RESPONSIBLE TO COMPLETE ALL HOMEWORK ASSIGNMENTS IN THE ALLOTTED TIME GIVEN. CLIENT MAY CONTACT BEHAVIOR PROFESSIONAL IF THERE ARE EXTENUATING CIRCUMSTANCES OR IF THERE ARE QUESTIONS OR PROBLEMS PROHIBITING THE COMPLETION OF THESE TASKS, SO THAT THE BEHAVIOR PROFESSIONAL CAN ASSIST THE CLIENT IN WORKING THROUGH THE ASSIGNMENTS. CLIENT IS RESPONSIBLE TO SUBMIT ALL ASSIGNMENTS AND ABC DATA AT LEAST 48 HOURS IN ADVANCE OF EVERY APPOINTMENT. FAILURE TO DO SO WILL NOT RESULT IN CANCELATION OF THE APPOINTMENT, BUT WILL, HOWEVER, RESULT IN AN APPOINTMENT THAT MAY NOT BE AS PRODUCTIVE AS IT COULD/SHOULD BE. CLIENT WILL NOT RECEIVE REMINDERS, BUT MUST TAKE THE RESPONSIBILITY TO COMPLETE ALL REQUIRED TASKS BY THE SPECIFIED DATES/TIMES.

CLIENT/OWNER UNDERSTANDS THAT THERE ARE NO GUARANTEES MADE BY CAROLYN KOCMAN, PET BEHAVIOR SPECIALIST, LLC (AND ITS REPRESENTATIVES) THAT THE PET WILL NOT CAUSE INJURY TO HUMANS OR OTHER ANIMALS OR DAMAGE TO PROPERTY IN THE FUTURE. CLIENT/OWNER WILL BE SOLELY RESPONSIBLE FOR FUTURE PET BEHAVIOR. 

AGREEING BELOW ACKNOWLEDGES THAT THE CLIENT/OWNER RESUMES THE RISKS AND WILL HOLD HARMLESS CAROLYN KOCMAN, PET BEHAVIOR SPECIALIST, LLC AND ITS REPRESENTATIVES WITH REGARD TO ANY LOSS, DAMAGE, OR INJURY WHILE EMPLOYING ANY RECOMMENDATIONS. 

ONCE SUBMITTED, YOU WILL BE CONTACTED WITH A DATE/TIME FOR YOUR APPOINTMENT (CONFIRMED ONCE PAYMENT IS MADE) AND AN ADDITIONAL DATA FORM.

PLEASE REMIT THE ABC SHEET (SENT TO YOUR EMAIL) AT LEAST TWO DAYS PRIOR TO YOUR FIRST APPOINTMENT AND CONTINUE TO KEEP THIS LOG THROUGHOUT YOUR BEHAVIORAL JOURNEY.