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For your review. A printed copy will be presented at the first session for your signature.

You may print this for your records if you wish.

Client Refusal to Authorize and/or Pay for

Recommended Behavior Modification or Veterinary Behaviorist Referral

Nutz About Mutz! (Jody Epstein, CPDT-KA)



Client’s name __________________________________________________________________

Name of Pet ____________________________________________________________________

Species _______________________________________________________________________

Breed _________________________________________________________________________


_____ I, the undersigned owner of the pet(s) identified above, being 18 years of age or older, am authorized to make decisions regarding its case.


_____ I hereby acknowledge that my trainer, Nutz About Mutz! and Jody Epstein, has recommended or offered management options, behavior modification and/or referral to a veterinary behaviorist for my pet’s handling-related or behavior-related issues.


I decline these recommendations (circle the ones offered that you decline)


  • Management In Home and/or In Public (e.g. barriers, basket muzzles, etc)

  • Behavior Modification

  • Veterinary Behaviorist Referral


_____ I understand my pet is showing aggressive tendencies (including, but not limited to: resource guarding, fear-aggression, or status-related aggression) and behavior displays including, but not limited to: cowering, trying to escape, growling, showing teeth, snarling, fixated focus, snapping, lunging, biting and other stress related behaviors.


____ I understand that by declining the above recommended services the current behavior issues are likely to escalate and a major bite incident may occur.


_____ Continued opportunity to practice escalating aggressive behaviors (e.g. growls, barks, fixated focus, lunges, snaps, bites) will raise my dog’s base line arousal for such behavior, causing her/him to trigger more easily and become more aggressive, possibly without warning prior to a bite.


_____ I agree to hold Nutz About Mutz! and Jody Epstein harmless for any adverse behavioral effects that result from declining these services.


_____ I agree that I, the legal guardian of the above named dog(s), shall be held solely and completely financially responsible for any damage or injury to a human, another animal or property that incurs a cost to repair.




   _________________________________________________                   ___________________

            Signature of Owner or Authorized Agent                                             Date



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