Healing on Manes Registration
Trauma Informed Equine Assisted Learning
Client Information
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Ethnicity
Please Select
Black or African American
White
Hispanic or Latino
Asian
Native
Pacific Islander
Multiple Race
Other
Gender
*
Please Select
Female
Male
Transgender Male
Transgender Female
Non-Binary
Agender/I don't identify as any gender
I prefer not to state
Family Information
Please share the following information regarding the client's family
How many immediate family members are in your household?
*
Please Select
1 Member
2 Members
3 Members
4 Members
5 Members
6 Members
7 Members
8 Members
9+ Members
Client History
*
Adopted
Raised with Biological Parents
Kinship Care
Foster Care
How much total combined income did your HOUSEHOLD earn last year?
Please Select
Less than $12,140
$12,141 - $16,460
$16,461 - $20,780
$20,781 - $25,100
$25,101 - $29,420
$33,741 - $38,060
$38,061 - $42,380
$42,381 -$46,700
$46,701- $51,020
$51,021 - $74,999
$75,000 - $99,999
$100,000 - $124,999
$125,000 - $149,999
$150,000 - $174,999
$175,000 - $199,999
$200,000+
Are you or any member of your household currently receiving any of the following:
Food Stamps
WIC
SSI
Medicaid
Medicare
TANIF
Contact Information
Please provide the following contact information for the client
Caregiver's Name
First Name
Last Name
Is the above adult the client's legal guardian?
Yes
No
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact (Please choose someone who would be locally accessible in case of emergency at the farm)
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Client Description
Please indicate what you feel comfortable with sharing with us so that we may best serve the client
History of:
ADHD
Anger
Anxiety
Bullying
Community Violence
Conflict
Depression
Domestic Violence
Emotional Abuse
Family Divorce
Family Separation
Frequent Relocation
Gangs
Grief
Labor Trafficking
Learning/Cognitive/Disability
Loss
Military/First Responder
Neglect
OCD
ODD
Parental Death
Parental Incarceration
Parental Substance Abuse
Personal Substance Abuse
Physical Abuse
Physical Limitations/ Medical Diagnosis
PTSD
School Violence
Self Harm
Sex Trafficking
Sexual Abuse
Suicide Attempts
Suicidal Ideation
Suicide Threats
Traumatic Experience
Truancy
Verbal Abuse
Other
Currently Struggles With:
ADHD
Anger
Anxiety
Conflict
Depression
Destructive Behaviors
Empathy
Grief
Learning Diabilities
Low Self Esteem
OCD
ODD
PTSD
Relationships
School Performance
Self Harm
Self Talk/ Self Worth
Sensory Processing
Suicidal Ideation/Threats
Suicide Attempts
Other
Do you feel the client is currently experiencing a crisis? (If so, please call 9-1-1 or 9-8-8)
*
Yes
No
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
*
Boundaries
Comfort
Communication
Confidence
Empathy
Improved Participation in School/Life
Improved Relationships
Improved Self-Talk/Feelings
Leadership
Listening Skills
Respect (self/others)
Responsibility
Self Control
Self Esteem
Self Expression
Sense of Belonging
Sense of Purpose
Sense of Safety
Sense of Value/Worth
Social Skills
Trust
Other
Client Strengths & Character Traits
How did you hear about Healing on Manes?
In Person Flyer
Radio
Referral from School
Referral from Counselor/Therapist
Social Media
Word of Mouth
Other
Is this client currently under the care of a Therapist/Psychologist?
Yes
No
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?
*
Yes
No
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 Name
Last 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)
*
Tuesday 5pm
Tuesday 6pm
Wednesday 5pm
Wednesday 6pm
Thursday 5pm
Thursday 6pm
Spring (April-May)
Summer (June-July)
Fall (September-October)
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