FCVA Youth Intake
This form is intended for clients under 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.
Youth Name:
*
First Name
Last Name
Preferred Name:
Referred by:
Parent/Guardian's Name (if applicable):
First Name
Last Name
Demographic Information
Youth 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
Is the youth currently employed?
*
Please Select
Yes
No
Others living in the home (Names/Relationship/age)
Please share any significant youth life and family history?
Medical and Psychological history
Please list any youth current health/medical concerns, conditions, diagnosis, or allergies (ex. Asthma, bee allergies, heat sensitivity)
*
Is the youth on any medications that would impact participation in outdoor and animal-based activities? (sun sensitivity, slowed response time)
*
Yes
No
Possibly
If you answered yes or possibly to the previous question, please explain below:
Does the youth currently have any substance use/abuse/dependence issues?
*
Yes
No
Has the youth had any aggressive, violent or abusive incidents involving animals?
*
Yes
No
If yes, to the previous question, please explain below.
Back
Next
Personality Traits & Goals
Describe the successes strengths and qualities of the youth
*
Describe the challenges, obstacles and needs of the youth.
*
What skills/goals would the youth be able to learn, improve, or address through time with horses?
*
Please provide any other information you think will be necessary or helpful.
This form was completed by:
*
Date
*
-
Month
-
Day
Year
Date
Signature
*
Continue
Continue
Should be Empty: