Date of Visit *

MM

DD

YYYY

Time of Visit *

Hour

Minute

Second

AM PM

Supervising Member Name *

First Name

Last Name

Supervising Member Phone *

(###)

###

####

New Member Name *

First Name

Last Name

Dog appears freshly clean and well groomed, including clean paws and trimmed nails? *

Yes

No

Dog looks and acts healthy? *

Yes

No

Dog is friendly toward people? *

Yes

No

Dog willingly goes to them and accepts being petted? *

Yes

No

Dog jumps up on people without being invited? *

Yes

No

Dog stares too much at other dogs on visit? *

Yes

No

Dog growls at other dogs on visit? *

Yes

No

Dog lunges or strains at leash toward other dogs on visit? *

Yes

No

Owner is able to get and keep the dog’s attention whenever necessary? *

Yes

No

Dog moves beside owner on a relaxed, loose leash going down hallways? *

Yes

No

Owner has verbal control of dog rather than jerking or tugging on leash? *

Yes

No

Owner shows good judgment of placing dog to easily be reached by people? *

Yes

No

Owner has control of the dog at all times, using sit or down stays when needed, such as waiting their turn when with other teams? *

Yes

No

Dog shows signs of stress such as reluctance, tucked tail, yawning, excessive panting (unless rooms are warm), licking, or scratching? *

Yes

No

IN YOUR OPINION, DOES THIS ANIMAL AND HANDLER MEET OUR REQUIREMENTS FOR THERAPY VISITS? *

Yes

No