FCVA Adult Intake
This form is intended for clients over the age of 18 that have been requested to complete the Intake by Flying Changes staff. This information is helpful in guiding the equine activities and plans while working with the Flying Changes team. DO NOT COMPLETE THIS FORM UNTIL REQUESTED.
Client Name:
*
First Name
Last Name
Preferred Name:
Referred by:
Parent/Guardian's Name (if applicable):
First Name
Last Name
Demographic Information
Client Age:
*
Preferred Pronouns
He/his
She/hers
Other
Type of residence
*
Live independently
Live with parent
Live in a relative/friend's home
Live in a foster home
Live in an adoptive home
Other
Are you currently employed?
*
Please Select
Yes
No
Partner Status
*
Single
Married/partnered
Divorced
Widowed
Do you have children?
*
Yes
No
If you have children, how many and what ages?
If you have children, where do they live?
Others living in the home (Names/Relationship/age)
Do you have any significant life and family history?
Medical and Psychological history
Current health/medical concerns, conditions, diagnosis, or allergies (ex. Asthma, bee allergies, heat sensitivity)
*
Are you on any medications that would impact participation in outdoor and animal-based activities? (sun sensitivity, slowed response time)
*
Yes
No
Maybe
If you answered yes or maybe to the previous question, please explain below:
Do you currently have substance use/abuse/dependence issues?
*
Yes
No
Have you ever been aggressive, or arrested/convicted of a crime or felony involving animals?
*
Yes
No
If yes, to the previous question, please explain below.
Back
Next
Personality Traits & Goals
Describe your successes strengths and qualities:
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Describe your challenges, obstacles and needs.
*
What would you like to learn, improve, or address through your time with horses?
*
Please provide any other information you think will be necessary or helpful.
This form was completed by:
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Date
*
-
Month
-
Day
Year
Date
Signature
*
Continue
Continue
Should be Empty: