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Dog: ____________________________ Date Adopted: _____________________
Adopter: ____________________________________________________________
Phone Number(s): ____________________________________________New? Y N
Address: ___________________________________________________ New? Y N
Email: _____________________________________________________New? Y N
MAESSR INTERVIEWER: _____________________________________________
DATE: ___________________________ Interview at 3 months or 1 year? _______
A. General topics to assess the dogs’ overall adjustment
Adjustment to new home
Primary Care Giver
Co-existing with other pets
Are there children in the home/How does the dog interact/react?
Comfort level with all adults
Anxiety and/or clinginess
Aggression or fearfulness
B. General topics to assess any owner questions and “Fit”
House training problems
Dog: _________________ Owner: ________________________
Any Excessive Barking or chewing
Diet and exercise
Was the dog taken to the vet since adoption?
Up to date on Vaccines? On Heartworm/Flea preventative?
Have you transferred the Microchip from MAESSR into your name?
Have they taken dog to obedience training (dogs under 1 yr old it is required by MAESSR)
Any problems or concerns that MAESSR can help with?
ALWAYS ASK IF WE CAN HELP (referrals and extensive network of ESS-knowledgeable volunteers)
C. Feed back for MAESSR
How long did you wait to adopt?
Did the adoption process go smoothly?
Do you have any recommendations for us?
ASK IF THE WOULD BE INTERESTED IN JOINING US AS A VOLUNTEER. MENTION POSSIBLE ROLES (I.E.: INTERVIEWS, TRANSPORT, FOSTER, ETC.)
D. Interviewers comments
Does the family seem happy and committed to the new springer?
Any comments/problems that caused concerns?
E. Gentle reminders for the owner at adoption contract terms
Telephone MAESSR immediately if the dog is lost or stolen
Notify us promptly of any new address and contact info
If they wish to relinquish the dog, they must notify MAESSR so we can reclaim it.
MAESSR dogs may not be given to another person/organization/company without our approval
Post Adoption follow-up calls the first at three months then at a year
This is for your information, you do not need to send this page to Debbie
F. Interview Follow-up
Mail completed post adoption forms to:
Debbie Lipcsey
c/o MAESSR
3205 Davis Mill Road
Goochland, VA 23063
Or email: springerfarm@
Email the following information to Pat Alberta at PAlberta207@
1 Owners name
2 Dogs name
3 Interview date
4 New contact information (if applicable)
5 Interested in volunteering
6 Further contact needed? (behavioral issues, relinquishment, training, health, etc.)
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