Glimmer Dog Application

Let’s get started with the Glimmer Dog Program!

I want to make sure that I am the right professional fit for you. I am an "all in" Family Dog Mediator and I work best with clients who are very invested in their own and their dog's well-being. If you're ready to learn and do the work, I am 100% ready to support you and give you my very best.

The following statements are designed to help you understand my process and services. Please read and check the boxes to indicate that you understand and agree.

Glimmer Dog Program Application - Checkbox

I have read the Glimmer Dog Program page on the website and reviewed the pricing information.

I understand that I will be engaging in a collaborative process that takes into consideration everyone's welfare and needs before beginning a behavior change protocol.

I understand that I will have work to do with my dog and on my own understanding, beliefs, and behaviors in between our sessions.

I understand that human and dog behavior is nuanced and complex and that there are no quick fixes or magic formulas.

I understand that progress is not linear and that behavior change takes time.

I am willing to communicate my needs, feelings, and comfort level through each step of this process and understand that Tara will not ask me to do things that I am not ready for or comfortable with.

I am ready to engage in the work involved and time commitment to meeting my dog’s needs on a daily basis including exercise and enrichment.

I'm ready to get to work, have fun, and grow in my relationship with my dog. Let's GO!

Are you willing to make adjustments to your current lifestyle to meet your dogs needs and set our training up for success? (e.g. putting up a baby gate, providing more exercise for your dog, etc)

Yes

Are you willing to seek additional assistance from a veterinarian or veterinary behaviorist if I recommend it for your dog's particular concerns?

Yes

Are you willing to use medication if it is recommended by the veterinarian or veterinary behaviorist?

Yes

Today's Date

Names and ages of all members of the household

Is there anything I can do to make the learning process easier, specific to each member of the family? What is the learning style that is most effective for each family member? Does any member in the family have a diagnosis or need that I should be aware of in terms of how they learn or need information presented or need any physical ability accommodations?

Name of person completing this form *

Home address *

Preferred phone number *

Email address *

I understand that Tara Stillwell will do her best to accommodate my scheduling needs within weekday business hours EST.

Yes

This won’t work for me, please contact me with other options.

Dog's name (if more than one, separate with comma and follow the same order in subsequent fields)

Breed(s)

Sex, Neutered/Spayed (Y/N)

Weight

Age of dog(s) today

Age at acquisition

Date of birth, if known

Breeder or Rescue Group Name

Please give any additional details about the methods of the breeder, your dog's parents, or any additional information on the dog's history from the rescue organization or shelter:

Vet Clinic Name

Vet Name and Phone #

Referred by

Has your dog ever bitten a person or dog? If yes, please give details.

Yes

What is your main goal for our work together?

What are your main questions or concerns in working towards your main goal together?

Once you submit this form you will receive a response with answers to any questions and instructions on scheduling your initial consultation.

I understand and will check my email for payment and scheduling information.

I have a few questions I need answered before I'm ready to start.

Here are the questions I have before I get started with Glimmer Dog: