Client Waiting List
Wellness Ranch Equine-Assisted Therapy Client Form: Please fill out the following information so the Wellness Ranch team can contact you regarding upcoming appointment availability. At Wellness Ranch, we provide mental health therapy incorporating horses and other healing companions in a safe, supportive environment. Our approach is unmounted—we do not offer horseback riding. We believe healing happens through connection, relationship, and presence: heart to heart and eye to eye.We look forward to learning more about you and how we can support your journey toward hope, healing, and wellness.
Name
*
First Name
Last Name
Child/Adolescent/Young Adult
First Name
Last Name
Phone Number
*
Best number to reach you
Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Date of Birth
*
Example: January 1, 2020 of future client
What days and times work best for your schedule for future sessions? We are closed on weekends to allow our healing companions time to rest and recharge.
*
Example: Mon & Tuesday after 3pm, Mornings between 9am-11am
Write: Inland Regional / Insurance type / Private pay
*
Example: Self-Determination Program, Private Pay (Zelle, PayPal) We are currently approved for the following insurances: Aetna, Anthem Blue Cross California, Blue Cross Blue Shield of Massachusetts, Blue Shield of California, and Cigna.
Is your child currently receiving services through a Regional Center?
Yes
No
In the process of applying
Unsure
If yes, please upload your child’s most recent Regional Center evaluation or assessment report. (Optional but highly encouraged)
Upload a File
Drag and drop files here
Choose a file
Cancel
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What are somethings you would like us to know about you or your child? How did you hear about us?
*
How can Wellness Ranch best support you?
*
Example: Communication, anxiety, depression, life transition
Parent Concerns
Anxiety or excessive worrying
Difficulty managing emotions
Frequent tantrums or meltdowns
Anger or aggression
Defiance or difficulty following directions
Social difficulties or trouble making friends
Low self-esteem or negative self-talk
Sadness or withdrawal
Difficulty with transitions or changes in routine
Attention or focus concerns
Hyperactivity or impulsivity
Sleep difficulties
School-related stress
Grief or loss
Family changes (divorce, separation, move, etc.)
Trauma or stressful life events
Self-harm concerns
Suicidal thoughts or statements
Substance use concerns
Excessive screen time or gaming concerns
Sibling conflict
Other
Submit
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