Prospective Intake Questionnaire

This questionnaire is for people who are considering surrendering their dog for adoption.

Intake priorities are given to senior citizens or chronically/terminally ill people who can no longer care for their dog as well as for dogs whose guardian has passed away. We focus on taking in dogs from Monterey, Santa Cruz, and San Benito Counties, but from time to time we can make exceptions.

In order for us to take in your dog, your dog must be excellent with people including strangers they have just met. Your dog must also get along well with other dogs with no signs of aggression. If your dog gets along well with children and/or cats, that is a bonus. Before intake, your dog needs to pass an evaluation by a POMDR representative.

We are able to take in dogs with medical issues from time to time, but space is limited for dogs with major medical issues. This will be evaluated on a case by case basis.

To get started please answer the following questions, and please submit one form per dog you need help with.

Your Information

Name *

First Name

Last Name

Email *

Verify Email *

Email again *

Please enter the same email address again

Verify Email *

Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Home phone *

Cell phone *

What is your preferred means of communication? *

Home phone

Cell phone

Text

What is the name of the legal owner of this dog? *

What is your relationship to the dog's owner? *

Age of the owner (not age of the dog)

Other *

Dog's Information

Dog's name *

Breed *

If your dog is a mix, list the one or two most prominent breeds

If you can, please supply one or two photos of your dog

Photo 1

Photo 2

Dog's weight *

Dog's age *

Dog's gender *

Male

Female

Is the dog spayed/neutered? *

Yes

How long have you had this dog? *

Where did you get this dog? *

Has this dog ever bitten a person? *

Yes

Explain *

Why are you looking to re-home this dog? *

Guardian passed away

Guardian is ill or physically unable to care for dog

Guardian moved to nursing home, assisted living, or senior home

Dog has behavior issue

Other

Explain *

How quickly do you need a place for this dog? *

When did this dog last see a vet? *

Can you provide medical records? *

Yes

Please give name of the vet clinic and person's name the records are under *

Does your dog have any current medical issues? *

What training does this dog have?

Check all that apply

House trained

Crate trained

Walks well on leash

Basic commands

Other

Explain other training *

How does your dog get along with other dogs in general? Are there particular types of dogs your dog doesn't get along with? *

How does your dog respond to dogs when out on a walk? *

For example: ignores, politely sniffs, gets excited, barks

How does your dog respond to people he/she meets in public for the first time? *

How does your dog respond to new people who come to the house? *

How does your dog respond to children? *

How does your dog respond to cats? *

What is your dog's energy level? *

For example: calm, needs a lot of exercise, doesn't have a stop button, settles at home nicely

How does your dog respond if you try to take away a bone, food dish, or favorite toy? Does he/she growl or snap? *

Where does your dog sleep at night? *

Is your dog indoors or outdoors during the day? How many hours is he left alone on a typical day? *

How does your dog respond to being left at home? Does he or has he ever exhibited any of these behaviors: whining, excessive barking, destructive tendencies, drooling, shaking, pacing, panic, breaking out of a crate, etc? *

Additional Information

Would you be able to make a donation to help us care for your dog and help us carry on our mission? If so how much could you donate?

A donation is not a requirement, but it can make a difference in whether or not we can take in your dog, and it does help us continue our work and cover your dog's expenses.

Less than $250

$500

$1000

$2500

Other

Other amount

Is there anything else you would like us to know about your dog or your situation?

Hit Submit. If a thank-you page does not quickly appear, scroll to the top of this page to see which information is missing.