KAD child questionnaire

KAD Child Questionnaire

1. Name

First

Last

2. Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

3. Phone

4. Email

5. Child's first name

6. Child's gender

7. Child's age

8. Does your child have any diagnosis that may impact the training?

9. When did the child first start to show signs of fear of dogs?

10. Did something happen to the child that made him or her scared of dogs? If so, what was it and when did it occur?

11. Did the child witness a negative event between a dog and a person? Or could someone have discussed with the child of a negative experience they had with dogs?

12. Is anyone else in the family or a close friend scared of dogs? If so, who? Have you noticed any similarities in the way they act around dogs?

13. Is the child scared of other things/animals/places? If so, what are they?

14. Is the child generally anxious?

15. How does the child cope with trying new things?

16. Does the child want to overcome her/his fear of dogs? Why?

17. How does the child act in the presence of dogs?

18. Is there a dog in the family or close friends? If so, what breed, age, gender and temper is the dog?

Please, make sure your child is in a space where an adult can easily check in with me during the sessions.

Do you agree for me to record the sessions (all recordings will be for my study and research only). The recordings will not be distributed, copied or shared with anyone else.

to what 9. When

Do you agree to allow me to use the material (feedback from our sessions, photos you sent me and the answers to these questions) in any future publication in relation to working with children on overcoming their fear of dogs?

Signature

Clear Signature

Date

Save and Resume Later

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