Clone of Youth Participant Registration Form

Participant Intake Form
Please contact Lindsey Polson with any questions regarding registration

Lindsey@animalsasnaturaltherapy.org Office: 360-671-3509
Date:

MonthDayYear
Date
Name of Participant

First NameLast Name
Participant Birth Date

MonthDayYear
Date
Gender Identity and/or Pronouns (please share what you are willing/comfortable)
Name of person filling out form and relationship to participant:
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
School participant is attending (if applicable):
Current grade:
Reason for seeking services:
Please list all members that live in the participant's primary household(s):
Please describe participant's social support system (i.e. therapist, psychiatrist, other services):
Please describe any animal experience the participant has, if applicable.
Please provide any mental or physical health diagnoses of the participant.
Current medication of participant:
For guardians: what specific changes do you wish to see happen for your youth during/after our program? For adult participants: what specific changes do you wish to see during/after attending our program?
Please check any of the concerns or symptoms listed below that the participant is currently experiencing:
Please provide any more information about the above answers or any other information we should know about the participant. Include anything that we did not cover in the above selections.
Participant Family History-select all that apply
Thank you!

The program coordinator will contact you with any questions or clarification needed after reviewing intake.
Should be Empty:

Participant Intake Form

Please contact Lindsey Polson with any questions regarding registration

Thank you!