Fox Moon Farm Intake Assessment Form

Intake Assessment Form

Please complete the following questions to help us understand you, or your loved one's needs or preferences.
Participant's Full Name*

First NameLast Name
Participant's Age*
Participant's Gender*
Participant's Date of Birth*

MonthDayYear
Date
Your Name

First NameLast Name
Your Phone Number*
Please enter a valid phone number.
Your Email Address*
example@example.com
Participant's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reason for Seeking Assistance*
Medical History*
Current Medications*
Allergies*
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*
Please enter a valid phone number.
Participant's Height
Participant's Weight
Participants' Diagnosis*
Physician*
Therapist*
Special Precautions or Needs*
Please indicate current and past special needs in the following areas, including surgeries:
Please click all that apply*

AllergiesLack of ConcentrationLearning DisabilitiesDevelopmentally DelayedBoundary IssuesSocial/Communication Skills problemsAnxiety/PhobiasDepressionSexual AbuseEmotional AbuseHallucinations/DelusionsSubstance Abuse problemsAnimal abuse or fire settingViolent tendenciesAny physical limitationEmotional DisregulationAnger MismanagementLack of Self Confidence/Self EsteemAutismADD/ADHDDementia/Alzheimer'sSeizures
Please explain date of onset-severity-treatment of any of the above checked items:*
Communication (style, understanding/comprehensive and ability to express needs):*
Best Learning Style:*

Visual/Learns by SeeingVerbal/learns by HearingKinesthetic/Learns by Doing
Favorites (i.e. food, colors, animals, subjects, etc.)
Sensitivities: (i.e.: smell, touch, sounds, etc.)
Any other special things we should know?
What is you or your loved one's biggest struggle in life right now?*
What are the top 3 life skills you would like for you or your loved one to learn through working in the Healing with Horses Program (in order of priority):*
What is a short term and a long term objective you would like to see you or your loved one achieve over the course of the Healing with Horses program?*
T-Shirt Size

SmallMediumLargeX-Large
To my knowledge, there is no reason why this person can not participate in supervised equine activities, which will include unmounted ground activities.
Signature*

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Date*

MonthDayYear
Date
Printed Name*

First NameLast Name
Relationship to Participant*
Should be Empty: