Equine Therapy Intake Form

Equine Therapy Intake Form

June's Second Chance Ranch
Name

First NameLast Name
Birth Date (JSCR currently only offers sessions to adults 18 and over)

MonthDayYear
Gender

MaleFemale
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which type of session are you interested in?

Single full therapy session with trail ride (75 minutes)- $654 week program 4 weekly, 75 minute sessions- $250Single therapy session (ground work only 45 minutes)- $40
Current weight: (we do have a weight limit of 240 to ride horses but there are no weight requirements for ground work therapy) if over 240 and you would like to still book a ground work session please note that here!
Are you a veteran or first responder?

Active or retired US MilitaryCurrent Police Fire or EMTNone of the above
Are there any injuries, surgeries, or recent health conditions that you feel the need to share with your instructors?
Do you have any triggers that we should be aware of? (Ie. Loud noises, barking dogs, airplanes etc)
Have you been diagnosed by a medical professional with PTSD or another trauma related illness? If so please list:
Have you tried any other forms of non conventional therapy? If so please list what you have tried and its effectiveness
How did you hear of us/ who can we thank for your referral?
Do you have any experience with horses? If yes, please state experience and comfortability with horses so we can pair you with the right horse.
Disclaimer: JSCR is an all volunteer run non profit program, all equine therapy instructors are trained volunteers but are not licensed therapists. We currently do not accept insurance and client intake is limited to donation funding and volunteer availability.

I understand that while JSCR strives to raise the funds to be able to offer equine therapy sessions at no charge to military members and first responders, there may be limited availibility of these sessions due to financial constraints.

I understand that there is a $20 deposit for booking a session at JSCR and if the session is not cancelled within 24 hours (unless there is an emergency) the deposit is non refundable.
Please sign below if you acknowledge the given information and give your consent to recieve

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