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Participant Assessment
To be filled out by teacher or legal representative of the participant
Your Info
Your Name
*
First Name
Last Name
I am the
*
Teacher
Parent
Legal Guardian
Case Manager
Other
My class is
*
Adaptive Riding
Advanced Horsemanship
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Participant Info
Participant's Name
*
First Name
Last Name
HIPAA Name
School
*
Teacher
*
Grade
*
Graduation Year
*
Diagnosis/Disability
*
Currently enrolled in:
Occupational Therapy
Physical Therapy
Other
Do they plan to enroll in any Vocational Rehab or other employment service agencies?
*
Yes
No
Please list the services/agencies:
*
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Participant Limitations
Speech/Hearing
*
Vision
*
Mobility
*
Adaptive/Medical Equipment
*
Other (Please Describe)
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Participant Goals
Goal 1
*
Goal 2
*
Current Employment Goals
*
Post Graduation Goals
*
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Participant Behaviors
Do they currently have a behavior plan?
*
Yes (Please upload)
No
File Upload: Behavior Plan
Browse Files
Drag and drop files here
Choose a file
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of
Behaviors
*
Triggers
*
Coping strategies or ways to redirect
*
*
Today's Date
*
/
Month
/
Day
Year
Submit
Should be Empty: