Dog Separation Anxiety Training Plan Form
Tell us about your dog’s separation-related behaviors, current routine, and training goals so a personalized training plan can be created.
Dog and Owner Basics
Owner Name
*
First Name
Last Name
Email
*
example@example.com
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Dog Name
*
Dog Age
Breed
Sex / Neuter Status
Intact Male
Neutered Male
Intact Female
Spayed Female
Unknown
How Long Have You Had the Dog?
Separation Anxiety Symptoms and History
When did the separation-related behavior first start?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How often does it happen?
*
Every time
Most times
Sometimes
Rarely
Not sure
Main symptoms when left alone
*
Barking or howling
Destructive chewing
House soiling
Pacing
Escape attempts
Drooling
Vomiting
Self-injury
Unable to settle
Other
Do the symptoms happen only when your dog is alone or also when you are present?
*
Only when alone
Also when I am present
Both
Not sure
Known triggers
Right before departure
Picking up keys or bag
Putting on shoes or coat
Closing doors
Changes in routine
Storms or loud noises
Other
What has already been tried to help?
Home Routine and Separation Context
Typical time the dog is left alone
Hour Minutes
AM
PM
AM/PM Option
Average duration alone (hours)
When alone, the dog is
*
Crate
Pen
One room
Free-roam
Other
Who the dog stays with if not alone
Where the dog stays when alone
Pre-departure routine
Departure and return behaviors observed
Rows
Observed
Not observed
Pacing
1
2
Vocalizing
3
4
Following closely
5
6
Clingy behavior
7
8
Hiding
9
10
Excessive excitement on return
11
12
Training Goals and Plan Constraints
Top Training Goal
*
Desired Outcome Milestones
Tolerates short alone-time periods
Stays calm during departures
Reduces whining or barking
Stops destructive behavior
Settles more quickly after being left alone
Can be left alone for a typical workday
Other
Preferred Training Style or Tools
Gradual alone-time training
Crate training
Enrichment activities
Camera monitoring
Calming routines
White noise
Pheromone support
Other
Weekly Time Available for Training
*
Less than 1 hour
1–2 hours
3–5 hours
More than 5 hours
Schedule Constraints or Upcoming Events
Access to a Camera or Monitoring Device
*
Yes
No
Unsure
Additional Plan Constraints or Considerations
Behavior Notes and Additional Details
Other household pets
None
Dog(s)
Cat(s)
Bird(s)
Small mammal(s)
Reptile(s)
Other
Recent changes at home
Veterinary or professional guidance already received
Additional notes for the trainer
Create Training Plan
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