Pathways Program – Client Intake Form
Please fill out the form below and a certified practitioner will be in touch with pricing and first time meeting information as soon as possible.
This application is for:
Individual Female
Individual Male
Parent & Child
Family
Date of Application:
Full Name:
Date of Birth:
Email Address:
Address:
Occupation:
Phone Number:
Marital Status:
Married
Single
Divorced
Separated
Widowed
Live in Partner
What are your preferred pronouns?
She/Her
Her/Him
They/Them
Other
Have you ever consulted a counselor, psychotherapist or psychiatrist before?
Please describe what you're hoping to explore, heal, or gain from equine-facilitated learning:
Have you participated in equine-assisted activities before?
Yes
No
Other
What are your goals for working with horses and animals in this setting?
Build Confidence
Reduce anxiety/stress
Improve emotional regulation
Navigate grief/loss
Support for ADHD
Other
If other, please describe:
What support systems do you currently have in place (e.g., therapy, peer groups, medication, family support)?
How did you hear about Pathways at Rewild Refuge?
Is there anything about your spiritual or religious beliefs you would like to share with Pathways?
Any other comments or information to better help us understand your situation and goals?
Do you have any allergies or medical conditions we should be aware of (e.g., hay, animals, bees, asthma)?
Do you have any physical or sensory limitations that might affect participation?
Are you comfortable being outdoors, around animals, and engaging in light movement (e.g., walking, grooming)?
Yes
No
Somewhat
I don't know
How do you typically respond to unfamiliar animals or situations?
Calm/curious
Hesitant/anxious
Avoidant
Other
What types of environments make you feel safe and supported?
Are there any emotional triggers or topics you’d like us to be aware of during your sessions?
I understand that the Pathways Program is an equine- and animal-assisted learning experience, not a licensed mental health service. I am participating voluntarily and understand that I may choose to stop or decline activities at any time. I affirm that the information provided above is accurate to the best of my knowledge.Participant Signature: ________________________. Date: _______________
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: