Animal Therapy Expression of Interest Form
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Parent / Carer Name
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Parent / Carer Email Address
*
example@example.com
Parent / Carer Contact Phone Number
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Parent / Carer Address
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Name of Child/Client
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Child/ Client Date of Birth
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Day
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Month
Year
Date
1st Emergency Contact Name
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1st Emergency Contact Phone Number
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1st Emergency Contact Relationship to Child
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What special interests does the child/client have?
Has your child/have you as the client, had a formal diagnosis? If Yes, please provide more info.
Describe your child's/you as the client, communication capability, i.e. non verbal, verbal with limited vocabulary, good communication
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Any specific environmental needs or triggers we should be aware of?
Would you/your child like a support person to join them during sessions?
What are you/they specifically hoping to achieve or work on during the sessions?
Have you as the client/your child tried therapy in the past? If so, what aspects did they/you find helpful and what did they/you dislike?
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Payment terms (invoicing will be after each session, and payable within 7 days)
*
Invoicing (including individualised funding)
Carer Support (please contact emma@positivepathways.nz when invoice is sent)
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