Berkman Academy Contact Details and Medical History

Berkman Academy

Contact details and Medical History
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
NDIS Number
Participant Phone Number (Under 18 provide guardian details)*
Participant Email (Under 18 provide guardian details)*
example@example.com
Experience with horses

No experienceOccasional interactionBasic horse experience on groundSome riding experienceHighly experienced, owned horses or ridden 10+ years
Client Profile
Are there any learning difficulties, mobility issues or other physical dynamics that will impact on participation? Please describe providing as much information as possible.
Is there any information about formal diagnosis you can share with us. Please describe providing as much information as possible.
Anything else that it is important for us to know? Please describe providing as much information as possible.
Does the participant experience any of the following? (Please tick all that apply)

AsthmaAllergic reactionsDiabetesHeart conditionBlood conditionRecent injuryEpilepsyPregnancyFaintingDizzinessBlackoutsMigraineBack injuryDisabilityMobility challanages (Using a walker or wheelchair)Uneven pupilsMedicationsHay feverOther
If you ticked "Other" please specify
Allergies - please describe and note reaction, treatment and prevention.
Mental Health & Neurodiverse Conditions

AnxietyDepressionPost-Traumatic Stress Disorder (PTSD)Attention Deficit Hyperactivity Disorder (ADHD)Autism Spectrum Disorder (ASD)Intellectual DisabilityLearning DifficultiesSensory Processing DisorderSpeech or Communication DifficultiesAcquired Brain Injury (ABI)Neurological Conditions (e.g., Multiple Sclerosis, Parkinson’s)Schizophrenia or Other Psychotic DisordersBipolar DisorderPersonality DisordersEating DisordersSubstance Use or Addiction History
Medication - Is it necessary for the client to carry medication? Please describe medication and usage.
Last Tetanus immunisation (Year)
Consent to medical attention

I authorise the therapeutic team to administer first aid and call an ambulance as deemed necessary. I will bear costs of ambulance.
Goals
NDIS participants share plan goals. Private clients share personal goals.
Emergency Contact
Contact Details for Emergency Contact Person*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Email
example@example.com
Emergency Contact Relationship to you
Medical and Health Related Contacts
General Practitioner
GP Name

First NameLast Name
GP Phone Number
example@example.com
GP Email
example@example.com
Psychologist / Psychiatrist
Psychologist / Psychiatrist Name

First NameLast Name
Psychologist / Psychiatrist Phone Number
Psychologist / Psychiatrist Email
Anything else you want to share with us regarding your contact information or preferences? Other Medical and/or Health Professionals - Please include contact name, phone number and email address
Signature of Client (Participant)*

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Signature of Legal Guardian (if under 18)

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Privacy Statement 1998

By completing this form, you are suppling the provider with personal information about yourself. This information is needed to ensure your safety during your time with us. The provider is required to collect this information by our insurance company and by the department of Workplace Health and Safety. This information you provide will not be supplied to any other organisation or used for any other purpose that that which is stated above.
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Berkman Academy

Client Profile

Goals

Emergency Contact

Medical and Health Related Contacts

General Practitioner

Psychologist / Psychiatrist