Equine Assisted Therapy Interest Form

Equine Assisted Therapy Interest Form
Today's Date:

MonthDayYear
Date
Client Information:
Name:
Age:
DOB:
Sex:
Weight REQUIRED: (180lbs - current max # for riding)
Parent/Legal Guardian 1 Name:
Relationship:
Address:
Contact Number:
Format: (000) 000-0000.
Email:
example@example.com
Parent/Legal Guardian 2 Name:
Relationship:
Address:
Contact Number:
Format: (000) 000-0000.
Email:
example@example.com
How do you see Equine Assisted/Animal Assisted Services being useful?
Which County are you in:
Are you part of any programs: Children's Long-Term Services (CLTS)
Program Interests:
Availability ~ Check ALL that apply:
Billing Information
CLTS or IRIS Contact:
Billing Agency Phone:
Format: (000) 000-0000.
Email:
example@example.com
info@csranch.org - 262-345-2163- 3128 Slinger Rd - PO Box 625 - Slinger WI 53086

Current Diagnosis:
Please list:
Any current medications or serious Illness or allergies to environment, foods, medications etc.?
Will the client be accompanied by a Support person/Behavioral assistant during session?
Support/Assistant Name:
Support/Assitant Phone:
Format: (000) 000-0000.
Email
example@example.com
Is there any history of client violence directed at people or animals? If yes please explain.
info@csranch.org-262-345-2163-3128 Slinger Rd-PO Box 625-Slinger WI 53086
Should be Empty: