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
Gender Identity and/or Pronouns (please share what you are willing/comfortable)
Name of person filling out form and relationship to participant (leave blank if filling out form for yourself)
E-mail*
example@example.com
Phone Number*
School participant is attending/grade (if applicable):
Reason for seeking services:*
Please list all members of the participant's household
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 parents: 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:*

Relationship problemsDifficulties with familyDifficulties with friendsSchool problemsFatigue/low energyDeath of significant person in participant's lifeAnxiety/worry/nervousnessPanic attacksPerfectionismGuilt/shame feelingsTrouble sleepingDepressed mood/sadnessSuicidal thoughtsSelf injuryEating habitsDrug abuseAlcohol abuseAnger/irritabilityExperience of verbal/emotional abuse (current or past)Experience of physical/sexual abuse (current or past)Loss of interest in previous activitiesDifficulty saying no to others/asserting selfTrouble with memory or concentrationFeelings of futility/loss of hopeLife transition (adjustment/change)Obsessive thoughts/excessive fearsImpulsive actionsDifficulty trusting othersLow self-esteemAvoidance of conflictWithdrawn, isolatingShy/uneasy around othersFear of failureHyperactivity/attention problemsHeadaches/stomach achesIdentity concernsNone of the above
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*

Abuse in the home-pastAbuse in the home-currentParticipant has people they are close to (family/friends) that are incarceratedSubstance abuse in the home-pastSubstance abuse in the home-currentWitnessed/experienced domestic violenceIs currently in foster careHas been in foster careIs adoptedUnstable housingNone of the above 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!