Healing on Manes Registration

Healing on Manes Registration

Trauma Informed Equine Assisted Learning
Client Information

First NameLast Name
Date of Birth

MonthDayYear
Date
Ethnicity
Gender
Family Information

Please share the following information regarding the client's family
How many immediate family members are in your household?
Client History
How much total combined income did your HOUSEHOLD earn last year?
Are you or any member of your household currently receiving any of the following:
Contact Information

Please provide the following contact information for the client
Caregiver's Name

First NameLast Name
Is the above adult the client's legal guardian?
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact (Please choose someone who would be locally accessible in case of emergency at the farm)

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Client Description

Please indicate what you feel comfortable with sharing with us so that we may best serve the client
History of:
Currently Struggles With:

Other
Do you feel the client is currently experiencing a crisis? (If so, please call 9-1-1 or 9-8-8)
Potential Areas of Development

Through Healing on Manes, our programs are designed to help individuals grow and develop personally including building strong relationship building skills, communication skills, and more.
Please identify the top five (5) outcomes that you wish to see in the client

Other
Client Strengths & Character Traits
How did you hear about Healing on Manes?

Other
Is this client currently under the care of a Therapist/Psychologist?
Do you identify with a place of worship? If so, where?
Does the client have any allergies? If so, please list all that apply
Please list any physical or mental limitations
Please describe any past or present assault/aggressive behavior
Is there history of animal abuse?
Please share any information that you feel may be helpful and relevant to the client participating in our program
Please state your name below to verify that the above information is true and accurate

First NameLast Name
Program Information and Availability

Clients participate in Healing on Manes with 1:1 sessions weekly for a period of 8 weeks. New elements are integrated each week to continue the client's personal growth throughout the program. This programming occurs 3 times during the year in Spring, Summer, and Fall.
Please indicate your availability for participation (Pleas select day/time as well as preference for session. Preference for session is not guaranteed)
Should be Empty:

Healing on Manes Registration

Family Information

Contact Information

Client Description

Potential Areas of Development

Program Information and Availability