Therapeutic Riding Intake Form

Therapeutic Riding Intake Form
Participant Name*

First NameLast Name
Parent/Guardian Name

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Please Describe the participants goals*
Participant Primary Diagnosis*
Participant Secondary Diagnosis*
Please provide all relevant Medical History*
Has the participant had (or is currently having) seizures? If so, please describe.*
Please provide type and date of last incident if applicable.
Does the participant use any assistance devices?*
Including wheelchair, cane, communication devices, etc.
Participant Age*
Participant Weight (used in consideration of the horse)*
Please upload any important files that you feel we should have.

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Do you have any additional comments, requests or questions for us?
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