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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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