Therapist/Teacher Questionnaire (Optional)

Healing Reins of Kentucky, Inc.2024 Therapist/Teacher Questionnaire (Optional)
Therapist/Teacher Questionnaire – Optional

Please provide as many as possible
Client Name:

First NameLast Name
DOB:

MonthDayYear
Date
Diagnosis:
Date of Request:

MonthDayYear
Date
The above named client has applied for equine-assisted activities and therapy sessions at Healing Reins of Kentucky, Inc. So that we may design a program that best accommodates and benefits the participant, we would appreciate your input.
Therapist/Teacher name:
Provider Type:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Phone Number:
Please enter a valid phone number.
In what capacity do you work with the participant?
How long have you known the participant?
Do you have any information that will help us be more successful while working with the participant?
Do you have any specific goals for the participant that you feel Equine-Assisted Services will help?
Therapist/Teacher Signature:

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Date:

MonthDayYear
Date
Provider Type:
License Number:
Should be Empty:

Healing Reins of Kentucky, Inc.2024 Therapist/Teacher Questionnaire (Optional)