Joplin Humane Society
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Cat Surrender Pre-screening Questionnaire
Joplin Humane Society only accepts animals from Southwest Missouri. If you are a resident of the Southwest Missouri areas and are in need of assistance, please complete the following form. You should submit one form per pet you are requesting to surrender or relinquish to the Joplin Humane Society. It is important that the answers provided for surrender questionnaires and assessments are honest and detailed.
This information is all JHS has to help set the pet up for success while in our care and in-depth information allows us to find the best outcome for the pet, including placement options and matchmaking for adoptions. Once you have submitted your questionnaire, a Pet Support Counselor will contact you to gather any additional information, discuss what options are best for the pet, and/or schedule an intake appointment for the pet to be surrendered to the Joplin Humane Society. If you have any questions, please call 417-623-3642 ext 3.
Thank you.
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Indicates required field
Name
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First
Last
Phone Number
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Pronouns:
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She/Her/Hers
He/Him/His
They/Them/Their
Other
Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Preferred method of contact:*
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Phone
Email
Preferred time of contact:*
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Morning
Afternoon
Have you used JHS services before?*
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Yes
No
Cat Information
Cat's name:
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Age and/or Birthday:
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Sex
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Male- Neutered
Male- Intact
Female- Spayed
Female- Intact
I don't know
Weight
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Color(s)
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Cat Breed
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Domestic Shorthair
Domestic Medium hair
Domestic Long Hair
Other
Distinguishing Markings:
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Optional: Please add a photo of your pet:
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Max file size: 20MB
Reason for Re-homing Your Cat
What is the reason for needing to re-home your cat?
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Allergic to Animal
Cannot Afford
Death of Owner/Family
Health of Owner/Family
Behavior Challenges
Change in Lifestyle
Health of Animal
Not a good fit with household/living arrangements
Housing Issues- Cost
Housing Issues- Moving/Relocating
Unwanted Litter
Other
Have you taken any steps to resolve or remedy the reasons that are causing you to re-home your cat?
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Yes
No
Are you willing to temporarily foster your cat until it can be adopted?
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Yes
No
If we could provide you with any of the following resources, would you be able to keep your cat?
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Outdoor Cat House
Kitty Litter
Crate/ Carrier
Flea Prevention
Spay/Neuter
Microchip
Collar
Cat Food
Vaccinations
Scratching Post/ scratching items
Behavior/ Training
Pet medical assistance
Pet Rent/ pet deposit assistance
None of these
Other
Are you interested in private re-homing through our Supported Re-homing Services?
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Yes
No
Unsure, give me more informatio
Cat Basic Information
Has your cat been vaccinated in the last 12 months?
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Yes
No
Unknown
Is your cat microchipped?
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Yes
No
Unknown
Primary Veterinarian (name, clinic, and contact information):
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Is your cat on any medications or special diet?*
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Yes
No
What brand of cat food do you feed your cat?
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How often is your cat fed?*
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Once a day
Twice a day
Other
Does your cat have any allergies or medical conditions?
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Yes
No
Unknown
Has your cat ever been tested for Feline Leukemia (FeLV)?
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Yes
No
Unknown
Is your cat declawed?
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Yes, front declawed
Yes, back declawed
Yes, completely declawed
No
Where did you get your cat from?
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Joplin Humane Society
Newspaper/website
Breeder
Pet Store
Owner rehoming animal
Friend/ relative
Found/ stray
Born in home
Craigslist/ Facebook
Animal shelter/ rescue
Where has your cat been living primarily?
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Indoors confined to a room
Garage
Outdoors on a cable, chain, or tie-out
Indoor free to roam
Outdoors free to roam
Both indoors / outdoors
Other
Has your cat ever been tested for Feline Immunodefiency Virus (FIV)?
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Yes
No
Unknown
If yes, how old was your cat at the time of surgery when the declaw surgery was performed?
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Has your cat ever been outdoors?
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Yes, without supervision
Yes, with close supervision
No, my cat has never been outdoors
Unsure
Other
General Behavior
How long is your cat left alone, without people, on a typical day?
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Never
1-3 hours
4-8 hours
9-12 hours
Over 12 hours
Is you cat litter boxed trained?
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Mostly, sometimes marks in the home
Yes, completely
No, frequently marks in the home
Unknown, cat lives outdoors
Please explain more about your cat's level of housetraining:
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What toys and games does your cat like?
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Balls
Feathers
Plush Toys
Wrestling
Tug Game
Toys that make noise
Fetch
Chase
Unknown
Other
When your cat plays, does he/she typically:
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Jump
Pounce on feet or ankles
Plays with toys
Grabs at you
Bite lightly
Bite hard
Unknown
None of these
Other
Is your cat afraid of anything?
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Yes
No
Unknown
Does your cat scratch furniture or use scratching posts / items?
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Yes
No
Is your dog allowed on the furniture?
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Yes
No
Please tell us your cat's "bad habits". If there aren't any, enter "none".Comment
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Please tell us something interesting, unique or fun about your cat, his/her traits, or personality that we can tell potential adopters:
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Behavior Around Other Animals
What other animals has your cat lived with?
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None
Cats
Dogs
Other
Has your cat ever attacked another animal resulting in severe injury or death?
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Yes, a dog
Yes, a small pet (hamster, guinea pig, etc.)
Yes, a cat
Yes, wildlife (birds, mice, squirrels, etc.)
No, my cat has never attacked another animal
None of these
Please describe the activities that led up to the injury or death of another animal by your cat:
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Has your cat ever reacted to other animal types by hissing, hiding, swatting or biting?
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Yes, dog
Yes, other cats
Yes, livestock
Yes, small pets (hamsters, guinea pigs, etc.)
Yes, wildlife (birds, mice, squirrels, etc.)
No, my cat has never reacted to other animals as described
Please describe the activities that led up to any snap or bite occurrence with an familiar pet:
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Behavior Around People
Has your cat bitten anyone in the last ten (10) days?
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Yes
No
Has your cat ever inflicted a bite to a person that broke the skin?
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Yes
No
Unknown
What types of people has your cat lived with?
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Infants/toddles
Small Children
Teenagers
Adults- Male
Adults- Female
Other
What ages were the children or teenagers?
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Has your cat ever reacted to a person by hiding, hissing, swatting, or biting towards any of the following populations:
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Yes, when approached by a familiar man
Yes, when approached by a familiar woman
Yes, when approached by familiar children
Yes, when approached by an unfamiliar man
Yes, when approached by an unfamiliar woman
Yes, when approached by unfamiliar children
No, my cat has never reached to other people as described
Please describe the activities that led up to any swatting or bite occurrence with a person or child:
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Is there any other information you would like us to know about your pet that may help us find the best placement options for this animal?
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Agreement
I am the owner or authorized agent/designee for the owner of the animal described above.
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I agree
The information provided in this questionnaire is accurate and true to the best of my knowledge.
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I agree
I understand that by submitting this questionnaire, it does not guarantee an appointment to surrender my animal(s) to Joplin Humane Society.
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I agree
I acknowledge that by completing this questionnaire I am requesting pet surrender support and/or services through Joplin Humane Society and that I will be contacted at a later date to discuss my pet(s) and schedule an intake appointment, if necessary.
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I agree
Signature
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Date
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Submit