Client Intake and Consent Form
This form ensures that I have up to date information for an accurate evaluation of your horse. The form must be submitted in order to confirm your booking. Please complete in detail to the best of your knowledge (one form per horse). Payment terms are outlined near the end of the form. Initial sessions are $175, and subsequent sessions are $130 (GST included). Please visit www.kaiti.com for more information about services provided, or reach out to me directly if you have any questions. I look forward to meeting you and your horse! Email: freetobe@kaiti.com Text: 778-835-0854
Today's Date
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Month
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Day
Year
Date Picker Icon
Horse Name
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Owner Name (or guardian name if leasing horse)
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Owner or Guardian Phone Number
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Would you like to receive information and updates from Free to Be Equine Services? If yes, please enter your email address.
example@example.com
If leasing the horse, do you have permission from the owner to book complementary therapy services?
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Yes
No
Not Applicable
Location of Horse (address, barn name if applicable, special instructions for locating the barn or parking)
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Horse Breed
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Horse Age
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Horse Gender
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Mare
Gelding
Stallion
Horse Colour
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Bay
Black
Chestnut/Sorrel
Brown
Grey
Roan
Palomino
Buckskin
Dun
Pinto Markings
Appaloosa Markings
Cremello/Perlino
Other
Current Veterinarian/Vet Clinic
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Current Hoof Care Provider
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How long have you owned/leased your horse?
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How often is your horse ridden or driven and under what circumstances/discipline (ie jumping, flat, trails, etc)? If not ridden please describe what other activities you do with the horse, if any.
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Does your horse have any notable long or short term health issues, injuries, or behavioural concerns? Please describe. Examples: cribbing, girthiness, dental issues, hoof issues, past or current major injuries/illnesses, difficulties with vet or farrier, pull-backs, history of lameness, history of colic, spookiness, anxiety, biting/kicking, etc.
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Where and how often is your horse turned out (time spent outside of their stall)? Please include duration, approximate size of turnout area, if alone or with other horses, and footing type(s).
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Is your horse fed free choice forage or timed feedings? Do they have any special supplements or diet considerations? Do they have any history of ulcers and if yes, how were they treated?
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What is your primary reason for contacting an Equine Therapist to work with your horse, and what goals are you hoping to achieve by doing so? Please describe.
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When was your horse last seen by their hoof care provider?
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Less than 2 weeks ago
Less than 4 weeks ago
Less than 8 weeks ago
More than 8 weeks ago
How is your horse currently shod?
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Barefoot
Front Shoes
All Around Shoes
Therapeutic/Corrective Shoes
Other
When was your horse last seen for dental work?
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Less than 6 months ago
Less than 1 year ago
More than 1 year ago
More than 3 years ago
Has your saddle been professionally fitted?
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Yes
No
It was fitted by someone other than a professional saddle fitter
I don't use a saddle or my horse isn't ridden
Is your horse currently under the care of a veterinarian for any reason, such as illness or injury? If yes, please describe the condition, or write "no".
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If you answered yes to the above question, have you consulted with your veterinarian about having bodywork performed on your horse? It is recommended that you consult with your veterinarian about complementary care for your horse, and to rule out any contraindications for doing so. If non applicable, please write "N/A".
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Does your horse currently take any vet prescribed medications or receive injections? Please list them below or write "no".
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Has your horse experienced any physical changes or changes in routine over the last 8 weeks? Examples: Injuries, illnesses, vet work, changes to hoof angles or shoeing protocol, hoof abscesses, moving barns, competitions, changes to feed, changes to tack, increase or decrease of work load, increase or decrease of turnout, etc. Please describe the changes and when they occurred.
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Other than your vet and farrier, is your horse under the care of any other equine healthcare professionals such as an equine nutritionist, osteopath, chiropractor or other bodyworker? Please state their name(s) and profession(s).
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While a single session can show positive results, follow-up sessions or a series of sessions are highly recommended. The nature of Kaiti's bodywork is gradual unwinding and peeling back of layers of compensation in the musculoskeletal and nervous systems. As with any equine bodywork modality, craniosacral and myofascial work can bring about fascial, muscular, and emotional releases for the horse which may result in revealing underlying compensations in the body. For this reason, it is crucial to understand the importance of consistency in equine therapy sessions, completing "homework" with your horse between sessions, and potential referrals to other equine professionals if/when needed. Do you acknowledge this?
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Yes
No
Unsure - please contact Kaiti to discuss
PAYMENT TERMS. Payment by cash or e-transfer is due in full at the appointment (time of service). Online payments (invoice payable by credit card) are accepted in advance of appointment only (please request). Please request a receipt if required. Invoices remaining unpaid after 48 hours are subject to a 10% late fee. An additional 10% late fee will incur weekly until the invoice is paid in full. Appointments cancelled/rescheduled with less than 48 hours notice are subject to a 50% cancellation fee. If you have prepaid and the appointment is cancelled by the service provider, you will be refunded in full. Do you agree to these terms?
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Yes
No
SCOPE OF PRACTICE DISCLAIMER. The services provided by Free to Be Equine Services are not a substitute for diagnosis and treatment from your horse’s equine veterinarian - Kaiti is not a veterinarian and cannot diagnose your horse nor prescribe medications. Equine Therapy provides a supportive, complementary service to your horse’s regular health care routine. If your horse is ill or injured, please contact your veterinarian. Being the authorized guardian or owner of this horse, you hereby give full consent and approval to participate with your horse in Equine Therapy Sessions with Kathlene (Kaiti) Elliott of Free to Be Equine Services. Do you acknowledge this?
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Yes
No
LIABILITY RELEASE. As the authorized guardian or owner of this horse, I hereby release, waive, and forever discharge Kathlene (Kaiti) Elliott and Free to Be Equine Services from all claims, demands, actions, and causes of action of any kind of nature. I, have read and understand the information on this form and agree to release the above named Certified Equine Therapist from any loss, damage, liability or injury arising out of, or resulting from, participation in Equine Therapy sessions. I acknowledge that activities with and around horses involve inherent risks of physical injury to participants, horses, to others, and to property, which I understand and expressly assume. I agree to release Free to Be Equine Services and its operator, Kathlene (Kaiti) Elliott, of all liability in regards to the spread of infectious diseases including COVID-19. I acknowledge that Free to Be Equine Services and Kathlene (Kaiti) Elliott are taking all necessary precautions against transmission of infectious diseases and cannot be held responsible for any damages or illnesses to myself, the horse, the property on which the appointment takes place, and anyone else who visits said property. I assume all responsibility surrounding Free to be Equine Services and Kathlene (Kaiti) Elliott conducting services on this property. Photos and/or videos of the horse may be taken during the appointment for record keeping purposes. Photos/videos are never shared without consent from the owner/guardian. Do you agree to these terms?
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Yes
No
PHOTO/VIDEO RELEASE. As the authorized guardian or owner of this horse, I hereby grant permission to Kathlene (Kaiti) Elliott and Free to Be Equine Services to take photographs and/or videos of my horse during Equine Therapy Sessions and related services for private applications such as record keeping, progress evaluation, and case studies. I also agree to support a small business by granting permission for photographs and/or videos of my horse taken during Equine Therapy Sessions to be used for public applications such as Free to Be Equine Services social media, blog posts, client education materials, and related communications. Personal information is never included without permission. Do you agree to these terms?
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Yes - I approve private use only such as record keeping and case studies.
Yes - I approve both private use, and public use for communications.
No - I decline use of photos/videos for any application.
How did you hear about Free to Be Equine Services?
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Referral from a friend
Referral from a vet/farrier/trainer/other professional
Social media
Website or search engine
Other
Please Provide Your Signature
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