New Client Application/Intake Form &#8211; Center Stage Athletics & Team CSFP

Withers & Wellness Equine-Assisted Services Questionnaire

Thank you for taking the time to complete this form. Withers & Wellness offers both equine-assisted coaching and equine-assisted psychotherapy. This form helps us learn more about what you are looking for so we can determine which service may be the best fit.

Choosing the Right Service: Coaching or Psychotherapy

Equine-assisted coaching is a non-clinical, personal development service. Coaching may be a good fit if you are looking for support with confidence, stress management, self-awareness, emotional regulation, life transitions, connection, leadership, boundaries, mindfulness, personal growth, or overall wellness. Coaching is not therapy, counseling, mental health treatment, or a substitute for care from a licensed mental health provider.

Equine-assisted psychotherapy is a clinical mental health service provided through a collaborative team that includes a licensed mental health professional and an equine specialist. This may be a better fit if you are seeking support related to anxiety, depression, trauma, grief, relationship patterns, emotional distress, mental health symptoms, or other clinical concerns. Our psychotherapy sessions use the Eagala model, which is ground-based and involves a licensed mental health professional, an equine specialist, horses, and the client.

You do not need to know which service is right for you before completing this form. If you are unsure, please select “I’m not sure” below, and we can help guide you toward the most appropriate option.
Client Information

Please complete the below information for the CLIENT.
What type of service are you interested in?

Other
Which statement feels most accurate for what you are looking for right now?

Other
Please check the box that applies.

Other
What is your relationship to the client?

Other
Client Name (First Last)
Client Email
Client Phone Number

Area CodePhone Number
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country
Client Age
Client Birthday

MonthDayYear
Date
If client is a minor, please indicate school grade level.
Client gender identity. How does the client identify? Please select the option that best describes you. This question is optional and helps us create a respectful and supportive experience.

Other
If you are NOT the client, please complete the following information.

If you are submitting on behalf of someone else, please complete the information below.
Name (First Last)
Email
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country
Goals, Needs, and Current Support

If you are completing this form as a parent/guardian, please feel free to express both your desire and your child's desires.
Is client currently experiencing a mental health crisis, active suicidal thoughts, thoughts of harming yourself or someone else, or another immediate safety concern? Please note: Withers & Wellness does not provide emergency or crisis services. If you are in immediate danger or need urgent mental health support, please call 911, go to the nearest emergency room, or contact the Suicide & Crisis Lifeline by calling or texting 988.

Other
Is client currently working with a therapist, counselor, psychiatrist, coach, medical provider, or other support professional?

Other
If yes, please feel free to share anything that would be helpful for us to know, including whether you are hoping to coordinate care or keep this service separate.
What led you to inquire about equine-assisted services, and what are you hoping to receive from the experience?
Please check any and all that interest the client about equine assisted services :

Other
Feel free to briefly describe or expand on any of the above checked responses.
Is the client in the care of a doctor and/or up-to-date on regular wellness visits?

Other
Feel free to add more detail here if needed.
Please check if the client struggles with or has experienced any of the following:

Other
Feel free to briefly describe or expand on any of the above checked responses.
Please check if the client has been diagnosed with any of the following by a medical professional:

Other
Feel free to briefly describe or expand on any of the above checked responses.
Please tell us a little bit about your/client's current "story." This may include things like limiting beliefs, past trauma, emotional blocks, communication challenges, or stress. Please provide as much detail as you are comfortable with.
Note: If you are not comfortable with or able to articulate/put into words your story here, feel free to say "I'd rather tell it with the horses" and that is what we'll do.
Now please tell us a little bit about what you would like your/client's story to be. What is your/client's goal(s) for Equine Assisted Services. How would you like your/client's story to change? What does life for you/client look like on the other side of this process? Please provide as much detail as you are comfortable with.
Note: If you are not comfortable with or able to articulate/put into words your new story here, feel free to say "I'd rather tell it with the horses" and that is what we'll do.
Horse Experience

Please keep in mind that NO horse experience is required for Equine Assisted Services.
Please check all the boxes that reflect the client's horse experience.

Other
Feel free to describe or expand on any of the above checked responses.
If you have any additional information you'd like to share with us or questions you'd like to ask? Please do so here.
Legal Disclaimer and Service Acknowledgment

Withers & Wellness offers both non-clinical equine-assisted coaching services and equine-assisted psychotherapy services.

Equine-assisted coaching is a personal development and wellness-based service. Coaching may support self-awareness, emotional regulation, stress management, confidence, communication, connection, leadership, mindfulness, and personal growth. Coaching is not psychotherapy, counseling, medical care, diagnosis, or mental health treatment.

Equine-assisted psychotherapy is a clinical mental health service provided in collaboration with a licensed mental health professional and an equine specialist. Psychotherapy services may involve discussion of mental health symptoms, trauma, grief, emotional distress, relationships, coping patterns, or other clinical concerns. Psychotherapy services may involve separate consent, privacy, intake, and documentation requirements.

Our equine-assisted psychotherapy services use the Eagala model, which is a ground-based, team-facilitated approach involving a licensed mental health professional, an equine specialist, horses, and the client. No riding is involved.

Completion of this form does not establish a coaching or therapeutic relationship. This form is used to help determine whether coaching, psychotherapy, a workshop, or another referral may be the most appropriate fit. If your needs fall outside the scope of Withers & Wellness services, we may recommend that you contact a licensed healthcare provider, mental health provider, or emergency service.

Activities involving horses carry inherent risks. Horses are prey animals and may behave unpredictably, including but not limited to moving suddenly, kicking, biting, stepping on feet, pulling away, or reacting to their environment. By participating in equine-assisted services, you acknowledge that these risks exist and that participation is voluntary.

If you have questions about whether coaching or psychotherapy is the right fit for you, please contact Withers & Wellness to discuss.
My signature below indicates that I understand the difference between equine-assisted coaching and equine-assisted psychotherapy, that completion of this form does not guarantee acceptance into services, and that Withers & Wellness may recommend a different service or referral based on my needs.
Please verify that you are human
Should be Empty:

Client Information

If you are NOT the client, please complete the following information.

Goals, Needs, and Current Support

Horse Experience