Therapy Client Supplemental Information

Therapy Client Supplemental Information
Performance Equestrian & Therapy Riding Academy (PETRA)
For therapy and adaptive riding clients only. Please complete this form AND the Rider Registration Package.
Client Name

First NameLast Name
Parent / Guardian Name

Parent/Guardian First NameParent/Guardian Last Name
Email*
Please provide an email so we can send you a copy of your completed form.
SECTION 1 — THERAPY CLIENT INFORMATION

PETRA does not share your personal information with anyone.
Primary Diagnosis (if any)Write "None" or a simple description (e.g., "Cerebral palsy", "Autism spectrum disorder", "Down Syndrome"):
Current Therapies (check all that apply)

Physical TherapyOccupational TherapySpeech TherapyOther/Comments:
Previous Therapies (check all that apply)

Physical TherapyOccupational TherapySpeech TherapyOther/Comments:

Functional Abilities
Help us understand how to best support you during sessions. Please describe any mobility considerations, such as: limited vision or hearing, assistance needed for mounting/dismounting, wheelchair use, walking supports, balance concerns, or any other physical needs. Don't worry — we'll follow up if we need more detail.
Goals
What would you or your child like to accomplish? You can say as little or as much as you'd like. (e.g., "We just want Naomi to experience horses as a safe, enjoyable exercise in her day.")
SECTION 2 — DOWN SYNDROME & SEIZURE INFORMATION
Down Syndrome / Cervical Spine Stability
The client has Down Syndrome or a diagnosis affecting cervical spine stability.
If checked, physician clearance is required prior to participation.
Seizure Information

Client does not have seizures (skip remainder of this section. Please sign, date, and submit this form)Client has seizures (complete all fields below)
Type of seizures:
Typical aura:
Motor activity during seizure:

Average seizure duration:
Post-seizure behavior and duration:
What should PETRA staff do if a seizure occurs?
Anything else we should know?
By signing, you agree to notify PETRA if the client's seizure frequency, type, or medications change, and to inform us if a seizure occurs the day of a lesson.
Signature

Parent/Guardian signature if rider is under 18
Print Name
Date

MonthDayYear
Date
Should be Empty: