PT/OT Interest Form

Thank you for your interest in our pediatric Occupational and Physical Therapy services. Healing Reins offers a unique, goal-oriented approach that blends evidence-based therapy with the healing power of nature, animals, and purposeful movement. Please complete the following form so we can better understand your needs.

A member of our team will follow up with you to discuss availability and schedule an initial evaluation. In the meantime, feel free to browse our website or view our therapist bios below.

If you have any questions, please contact Nicole Paris-Johnson, Program & Clinic Manager, at 541-382-9410 or nicolep@healingreins.org.

Child's Name:*

First NameLast Name

Current Age*

Date of Birth*

Date

Primary Diagnosis*

Secondary Diagnosis (if any)

Legally authorized parent or guardian*

First NameLast Name

Best contact phone:*

Area CodePhone Number

Best Contact Email*

example@example.com

PhoneEmailText

YesNoIn progress

Today's Date:

MonthDayYear

Occupational TherapyPhysical TherapyNot Sure- Please help guide me

Equine Movement (Hippotherapy)Farm animal interaction & Traditional Indoor Clinic-based TherapyNot Sure- Please help guide me

YesNo

If Yes, please list type(s) of therapy, frequency, and provider(s).

Who is your insurance provider (optional, but helpful)?

MorningsAfternoonsEvenings

Please share any specific availability or scheduling limitations:*

Is there anything else you would like us to know?

Healing Reins Therapy Service ~ Interest Form