Focused Lesson Program Assessment
Essential Information
Participant Name
First Name
Last Name
Participant Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Participant Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical & Health Information
Primary Diagnosis / Condition
Secondary Diagnosis / Health Concerns
Current Medications
Do you take any emergency/rescue medications? Please list below.
Allergies/ Diet Restrictions
Mental Health Diagnosis / Behavioral Concerns
Past Surgeries / Major Injuries
Goals & Preferences
What are your goals for this program?
i.e. build confidence, improve balance, gain social skills, learn life skills, etc.
How do you learn best?
i.e. visually, checklists, repetition, one-on-one, hand-over-hand, reward driven, etc.
What are your strengths?
Experience with Horses?
Please Select
None
Some
Experienced
Any additional information?
Submit
Should be Empty: