Canine Surrender Profile

Be a part of the HAWS community for pets and their people. Join our pack!

Canine Surrender Profile

We understand that surrendering an animal to a shelter can be very difficult, and you are likely concerned for your pet’s future. By completing this form, you will help us care for your animal during its visit, and place it appropriately, if placement is possible. Thank you for helping us do the best possible job to make your pet’s stay a pleasant and short one.

- Step 1 of 11

An appointment is requested so we are better prepared for your animal's arrival. Please call us at 262-542-8851 ext: 0 to set up an appointment.
This profile is vital in helping us place your dog in it's new adoptive home. Please allow at least 15 minutes to fill it out. This form will need to be filled out in one sitting.

Date / Time of Your Scheduled Appointment

Date

Time

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

If you are surrendering due to a behavior concern. Please note that we do offer 1:1 Behavior Consultations to help keep dogs in their current homes. You can contact the Behavior Department by calling 262-542-8851 ext: 204 or email [email protected].

Are you surrendering multiple dogs?

How many dogs are you surrendering? *

Are they: *

Bonded (must be rehomed together, have been together all their lives and will not do well separate)
Siblings from different litters
Siblings from the same litter
Parent & Child
Not related
Don't Know
Other

Please explain: *

Why are you surrendering your dog? *

Dog Behavior
Dog Health
Personal (Not related to the dog)

Please give us a more detailed reason why you are surrendering your dog: *

Dog Name *

Gender *

Male
Female
Unknown

Is your dog Spayed or Neutered? *

Yes
No
Unknown

Please list your dog's breed(s): *

Age *

How old was your dog when you got it? *

How long have you had your dog? *

Where did you get your pet from? *

HAWS
Breeder
Rescue
Other Humane Society
Pet Store
Other

Please Specify the Name of the breeder, shelter or rescue you got your dog from: *

Has your dog had any health concerns in the PAST? *

Yes
No
Unknown

Has your dog's health concern been diagnosed by a Veterinarian? *

Please give us the name(s) of the Veterinary Clinic(s) that diagnosed/treated the health concern: *

Does your dog CURRENTLY have a health concern? *

Please give us the name(s) of the Veterinary Clinic(s) that diagnosed/treated the CURRENT health concern: *

If there is a health concern, please indicate if it is 1 or more of the following conditions: *

Dental Treatment
Fatty Tumor
Mammary Tumor
Giardia
Diarrhea
UTI
Kennel Cough
Ear Infections
Eye Infections
Controlled Thyroid Condition
Controlled Allergies
Mats in Hair
Cherry Eye
Eyelid Entropion
Blockage/Obstruction
Urinary Blockages
Broken Limbs
Pyometra
Pregnancy
Ringworm
Chronic ear condition
Chronic skin condition
Chronic kidney condition
Chronic liver condition
Chronic heart condition
Prolapsed rectum
Heartworm
Parvo
Bladder stones
Orthopedic concerns
Seizures
Pu/Pd (excessive drinking/urinating)
Asthma
Heart murmur
Perineal urethrostomy
Vulvaplasty
Hip dysplasia
Cancer
Luekemia
Kidney failure
Liver failure
Heart failure
Diabetes
Distemper
Leptospirosis
Rabies
Blastomycosis
Incontinence
Other

Please list the other concern: *

When did the health concern start? *

Has the health concern(s) been resolved? *

Yes
No
Unknown

Are the health concerns currently being treated? *

Is the your dog currently taking medication (including flea/tick or heartworm)? *

Yes
No
Unknown

Please name the medications your dog is currently taking: *

Has your dog been to a groomer? *

Yes
No
Unknown

Please tell us the name of the groomer your dog went to: *

For Shelter Use: Pathway A, B, or C

Has your dog tried to bite/lunge at a person? *

Did the bite make contact with the person? *

Did the bite leave a mark? *

Yes
No
Unknown

What did the mark look like:

Indent that went away but did not bruise
Indent that went away but brusied
Scraped Skin but mark went away
Scraped skin left mark (did not bleed)
Deeper scrape that bled
Multiple tooth punctures caused by body part being pulled away or do being pulled off the person
Multiple tooth punctures where dog bit and immediately let go
Multiple tooth punctures where dog held onto person with bruising (may have shaken body part)
Mutiple tooth punctures in multiple places on person's body

Please explain what happened before the incident(s) occurred: *

How often does your dog try to bite/lunge at people? *

1-2x/day
More than 2x/day
1-2x/week
More than 2x/week
1-2x/month
Every few months
Only in certain situations

What situations does your dog try to bite/lunge at people? *

What have you done to prevent your dog from trying to bite/lunge at people? *

Has your dog tried to bite/lunge at another dog? *

Did the bite make contact with the dog? *

Yes
No
Unknown

Did the bite leave a mark? *

Yes
No
Unknown

What did the mark look like:

Indent that went away but did not bruise
Indent that went away but brusied
Scraped Skin but mark went away
Scraped skin left mark (did not bleed)
Deeper scrape that bled
Multiple tooth punctures caused by body part being pulled away or do being pulled off the dog
Multiple tooth punctures where dog bit and immediately let go
Multiple tooth punctures where dog held onto dog with bruising (may have shaken body part)
Mutiple tooth punctures in multiple places on dog's body
The other dog did not survive

Please explain what happened before the incident(s) occurred: *

How often does your dog try to bite/lunge at other dogs? *

1-2x/day
More than 2x/day
1-2x/week
More than 2x/week
1-2x/month
Every few months
Only in certain situations

What situations does your dog try to bite/lunge at another dog? *

What have you done to prevent your dog from trying to bite/lunge at other dogs? *

For Shelter Use: Pathway A, B, or C

Training History

What formal training has your dog had? *

Puppy class
Basic Manners or Obedience Class
Private Behavior Counseling
Other
None

Please give the name of the Training Facility: *

Please give the name of the Training Facility & Trainer: *

Please tell us what other training your dog has had: *

What was the reason for seeking training? *

Socialization
Basic Manners or Obedience
Behavior Concern
Other

Please tell us what your other reason was for seeking training: *

If you sought out training for a Behavior Concern, what was the concerning behavior(s)? *

Dog reactivity
Separation anxiety
Potty training/marking
Fearful of strangers
Exessive barking
Pulling on leash
Resource guarding
Growling/biting

How long did you participate in the training for the Behavior Concerns? *

Did the training help? *

Yes
No
Other

Please tell us what the training helped: *

For Shelter Use: Pathway A, B, or C

Resource Guarding

Does your dog guard or protect anything? *

What items does our dog guard? *

Food bowl
Furniture/bedding
Toys
Chews
People
Other dogs or animals
Space (kitchen/living room/bedroom/etc)

When did your dog start resource guarding these objects(age/year/month)? *

When does your dog resource guard? *

When eating out of food bowl
When eating bones or rawhides
Items on the ground
Items on the counter
When you are on furniture
When someone else is on furniture
When dog is on furniture
While playing with toys
Resting with a toy
Guards person when other dog is near
Guards person when other people interact
Guards person when laying next to them
Guards person on walks

My dog guards objects from the following: *

People
Other dogs
Cats
Other

Please explain: *

When guarding objects my dog displays the following:

Remains interacting with the object but is stiff
Eats faster
Tries to finish object before you can take it
Moves away with the object
Stands over the object
Growls
Lip curls
Shows teeth
Will snap or attempt to bite
Returns to object after snapping or attempting to bite
Does not warn but will bite if they are near the object
Other

Please explain: *

If you have treats or another high value item will your dog trade? *

Yes
No
Sometimes

Please explain *

Has your dog injured another animal or person when resource guarding? *

Please describe the incident and injury to another animal/person: *

What have you done to prevent your dog from resource guarding? *

For Shelter Use: Pathway A, B, or C

Separation Related Questions

Can your dog be left home alone? *

How long do you leave your dog home alone? *

How often do you leave your dog home alone? *

Do you leave your dog out in the house with no restrictions? *

Have you crated or confined your dog to a smaller area when you leave? *

Please explain: *

Can your dog be confined to a room or crate when they are left alone? *

Please explain: *

Do you have to leave your dog with a dog sitter or at daycare every time you leave? *

When I am getting ready to leave my dog will: *

Follow me from room to room
Follow me from room to room, while whining or barking
Pacing
Reluctant to go into room or crate when I am ready to leave (will go in no issues when you are home)
Other
None of the abbove

Please describe what else your dog does when you are getting ready to leave: *

When I am gone my dog will:

Grab items they are not supposed to have
Grab items they are not supposed to have and destroy them
Not eat from any food/treats that have been left out
Chew on furniture
Knock things over near exits/windows
Destroy windows and/or doorways
Chew walls/moldings/curtains
Scratch doors/window sills/glass
Try to break through doors/windows
Bark/whine the entire time I am gone
Chews on their crate but has not escaped
Has gotten out of a room or crate
Has injured themselves trying to escape
Urinates/defecates
Shaking
Self harm (excessive licking, chewing on paws or tail)
Other
None of the above

Please describe what else your dog does when you are gone: *

When I return home my dog is: *

Following me
Whining/barking
Jumping on me
Panting
Drooling
Injured
Other
None of the above

Please describe what else your dog does when you get home: *

For Shelter Use: Pathway A, B, or C

Fear, Anxiety, and Stress

Is your dog CURRENTLY taking a prescribed anti-anxiety medication? *

Please give us the Name of the medication: *

Has your Veterinarian/Trainer recommended your dog be given an anti-anxiety medication? *

Has your dog been prescribed an anti-anxiety medication PREVIOUSLY? *

Please give us the Name of the medication: *

What situations does your dog need anti-anxiety medication for? *

Have you tried any additional products to help relieve anxiety? *

What products have you tried and what was the effect? *

Did the additional products help? *

What is your dog afraid of? *

Car rides
Cars or trucks driving by
Loud or sudden noises
Thunderstorms
Vet visits
Care procedures (nail trims, ear cleaning, etc)
Vacuum cleaners
Fireworks
New environments
Strangers
Men
Women
Children
Other dogs
Cats
Other
Nothing

What else is your dog afraid of? *

What behaviors does your dog display when they are afraid? *

Trying to get away
Constantly scanning the enviornment
Pulling towards
Pulling away
Yawning
Lip licking
Panting
Whining
Body stiffens
Mouth tightly closed
Crouched body position
Tail tucked
Barking
Lunging
Growling
Won't take food/treats
Hair stands up on back
Showing teeth
Snapping/attempting to bite
Biting
Other

What other behaviors does your dog display when they are scared? *

Where does our dog display these behaviors? *

At home
Out on a walk
In our yard
Public places
Trails
In a car
In a new environment
Other

What other places does your dog display these behaviors? *

When did you first notice the fear/anxiety start? *

How frequently are you noticing these behaviors? *

Has the behavior...... *

Gotten worse/more intense over time
Gotten better/improved over time
Stayed the same

Have you made any of the following adjustments to manage the behavior? *

Not taking the dog to public places
Not taking the dog on wlks
Walking only during odd hours
Window film/curtains to block visual access
Playing music/tv
Crating/confining to another room when someone comes over
Using treats to distract
Leash or tether
Muzzling
Restraint
Medicating in expectation of fear
Other
None of the above

What else have you done to manage the behavior? *

For Shelter Use: Pathway A, B, or C

Human Directed Aggression

What is your dogs reaction to strangers entering the home? *

Friendly, seeks attention
Overly excited, jumps on them or licks their faces
Mounts or humps them
Ignores them
Hides, does not greet
Barks initially and then stops
Barks excessively and won't stop until the stranger leaves
Will growl or bark when the stranger stands up or moves
Backs away, then warms up quickly
Backs away, may growl if they come near
Stiffens and faces the stranger
Growls
Charges at the stranger
Snaps
Bites
Other

What else does your dog do when a stranger enters your home? *

What is your dogs reaction to strangers outside the home? *

Friendly, seeks attention
Overly excited, jumps on them or licks their faces
Mounts or humps them
Ignores them
Hides, does not greet
Barks initially and then stops
Barks excessively and won't stop until the stranger leaves
Will growl or bark when the stranger stands up or moves
Backs away, then warms up quickly
Backs away, may growl if they come near
Stiffens and faces the stranger
Growls
Charges at the stranger
Snaps
Bites
Other

What else does your dog do when they meet a stranger outside the home? *

Does your dog get along with the human members of the household? *

Please tell us who it is that they do not get along with: *

Please describe when the above family member(s) do not get along: *

Please describe what behaviors your dog does in response to the family member(s) above: *

How does your dog typically behave during a vet visit?

Tries to get away
Constantly scanning the enviornment
Hides
Whines
Stiff Body
Mouth tightly closed
Crouched body posture
Tail tucked
Barks
Lunges
Growls
Won't take food/treats
Requires muzzle
Requires restraint
Hair on back stands up
Shows teeth
Snaps/attempts to bite
Bites
Requires sedation
Vet/techs unable to handle
Other

What other behaviors does your dog show at a typical vet visit? *

Is there anywhere that your dog does not like to be touched? *

Can touch them anywhere
Head
Feet/nails
Underbelly
Ears
Mouth
Tail
Front legs
Back legs
Neck
Back
Rear end

What is your dog's reaction when they are touched by someone in the above area(s): *

Moves away
Stiffens
Growls
Shows teeth
Snapping/attempting to bite
Puts mouth on person
Bites
Unable to touch
Other

Please explain: *

For Shelter Use: Pathway A, B, or C

Dog Directed Aggression

How does your dog react when seeing another dog? *

Focus on the other dog, can get their attention, will take food
Ears forward, mouth closed, tail up
Vocalization (whining, barking)
Loses interest in food
Still or rigid, intense stare
Fur stands up on back
Will not look away unless dog is out of sight
Will fight through fence
Rushes towards other dog
Lunges toward other dog
Flips around on leash
Snarls or growls
When close will snap
When close will bite
Other

How else does your dog react to seeing another dog? *

Does your dog live with another dog(s)? *

How many dogs live with your dog? *

1 other dog
2 other dogs
3 or more dogs

Has your dog ever gotten into a dog fight? *

Who was the fight with: *

Other resident dog
Unknown dog
Family/friend's dog
Other

Who else was the fight with? *

Please describe the incident(s): *

Where was the fight(s)? *

Inside of home
Outside but on property
Dog Park
On walk
Daycare
Other

Where did the dog fight occur? *

Did your dog get injured or need medical attention? *

Did the other dog get injured or need medical attention? *

Yes
No
Unknown

What did the injury look like? *

Scraped skin left mark (did not bleed)
Deeper scrape that bled
Multiple tooth punctures caused by body part being pulled away or do being pulled off the dog
Multiple tooth punctures where dog bit and immediately let go
Multiple tooth punctures where dog held onto dog with bruising (may have shaken body part)
Mutiple tooth punctures in multiple places on dog's body
The other dog did not survive
Unknown
Other

Please explain: *

For Shelter Use: Pathway A, B, or C

Home Environment

If there is another dog(s) in the home, what is your dog's reaction to them? *

No other dogs in the home
Friendly and playful
Curious, but able to be called away
In different
Fearful, backs away
Barks
Growls/lip curls
Hyper focused on the dog, unable to call away
Other

What additional reactions does your dog have to the other dogs in the home? *

Are there any cats in the home? *

What is your dog's reaction to them? *

No other dogs in the home
Friendly and playful
Curious, but able to be called away
In different
Fearful, backs away
Barks
Growls/lip curls
Hyper focused on the dog, unable to call away
Other

How else does your dog react to the cat(s) in your home? *

Are there any rabbits or other small animals in the home? *

What is your dog's reaction to them? *

No other dogs in the home
Friendly and playful
Curious, but able to be called away
In different
Fearful, backs away
Barks
Growls/lip curls
Hyper focused on the dog, unable to call away
Other

How else does your dog react to the small animals in your home? *

Eating Habits

Does your dog have any known dietary restrictions? *

Please list your dog's dietary restrictions: *

What types(s) if food do you feed your dog: *

Dry kibble
Wet food
Raw food
Homemade food
Table scraps

How many times a day is your dog fed? *

1
2
3 or more times/day
Bowl is always full

How would you describe your dog's eating habits: *

Loves their food
Picky eater
Other

Please explain: *

Potty Habits

Does your dog ever have accidents in the house? *

Are the accidents: *

Urine
Stool
Both

How often does your dog have accidents in the home? *

Never
Daily
Weekly
Occasionally (a few times a year)

How often does your dog go outside to eliminate? *

Never
1-3 times/day
4 or more times/day

Does your dog signal to go outside? *

How does your dog signal to go outside? *

Is your dog trained to use a litterbox or pee pads? *

How long can your dog hold it? *

Not at all (Not housetrained)
1-4 hours
4-8 hours
8-12 hours

Is there anything additional you would like to share about your dog? *

Staff Reviewed By Signature & Date:

Help us continue our mission of ensuring the entire community treats animals and one another, with respect.