New Client Application/Intake Form &#8211; Center Stage Athletics & Team CSFP

Equine Assisted Coaching Questionnaire

Thank you for taking the time to complete this form. Information provided will help me determine the best possible coaching and/or learning experience for you.

PLEASE NOTE: If you are interested in family, other group coaching or team building, please contact me directly to discuss details. For individual coaching, please complete the information below. Please send an email to info@centerstageathleticscoaching.com for more information.
Client Contact Information

Please complete the below information for the CLIENT.
What is your primary interest in Equine Assisted Coaching?*

Individual coachingFamily or other group coachingTeam buildingOther
Please check the box that applies.*

I am completing this form for myself.I am completing this form for my child.I am completing this form for someone else.Other
What is your relationship to the client?*

SelfParentGuardianSpouseOther
Client Name (First Last)*
Client Email*
Client Phone Number*

Area CodePhone Number
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country*
Client Age*
Client Birthday*

MonthDayYear
Date
If client is a minor, please indicate school grade level.*
Client Gender*

FemaleMaleOther
If you are NOT the client, please complete the following information.

If you are submitting on behalf of someone else, please complete the information below.
Name (First Last)
Email
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country
Coaching Goals

If you are completing this form as a parent/guardian, please feel free to express both your desire and your child's desires.
What led you to inquire about equine-assisted coaching and/or what do you hope to accomplish from your experience?*
Please check any and all that interest the client about equine assisted coaching :*

Spending time with horses in natureConnection with self and othersDeveloping and/or improving life skillsMindfulnessStress managementAtunnement with self and othersImproved physical healthImproved mental healthImproved spiritual healthImproved confidenceImproved sense of wellbeingEmpowermentLeadership skillsTeam buildingIncreased or improved resilienceSomatic experienceTrust for self and othersSelf compassionImproved overall sense of wellbeingOther
Feel free to briefly describe or expand on any of the above checked responses.
Is the client currently working with any mental health or coaching professional?*
If yes, please describe below.
If yes, feel free to describe.
Is the client in the care of a doctor and/or up-to-date on regular wellness visits? *
If yes, please describe below.
If yes, feel free to describe.
Is the client struggling with any mental or physical health issues or limitations?*
If yes, please describe below.
If yes, feel free to describe.
Please check if the client struggles with or has experienced any of the following:*

NoneAddictive behaviorsAngerDifficulty concentratingRelational conflictsSuicidal thoughtsDomestic abuseBetrayalAlcohol useChronic health issuesDifficulty sleepingFatigueSelf harmEmotional abuseSexual abuseLoss of loved oneGeneralized anxietyDepressionDrug useLonelinessPhysical abuseSuicide attemptsSelf harm/cuttingFamily members addictionDisordered eatingTraumaFamily dysfunctionLack of connectionSocial anxietyLoss of a loved oneOther
Feel free to briefly describe or expand on any of the above checked responses.
Please check if the client has been diagnosed with any of the following by a medical professional:*

NoneAnxietyDepressionAlcohol or drug addictionBorderline personality disorderObsessive compulsive disorderPost traumatic stress disorderEating disorderOther
Feel free to briefly describe or expand on any of the above checked responses.
Please tell us a little bit about your current "story." Your story may include things like limiting beliefs, past trauma, emotional blocks, communication challenges, or stress. Please provide as much detail as you are comfortable with.*
Note: If you are not comfortable with or able to articulate/put into words your story here, feel free to say "I'd rather tell it with the horses" and that is what we'll do.
Now please tell us a little bit about what you would like your story to be. What is your goal(s) for Equine Assisted Coaching. How would you like your story to change? What does life for you look like on the other side of this process? Please provide as much detail as you are comfortable with.*
Note: If you are not comfortable with or able to articulate/put into words your new story here, feel free to say "I'd rather tell it with the horses" and that is what we'll do.
Horse Experience

Please keep in mind that NO horse experience is required for Equine Assisted Coaching.
Please check all the boxes that reflect the client's horse experience.

No horse experienceLove being around horses and/or other animalsLesson program experienceTrail riding experience (including on vacation)Competitive riderHorse ownerHorse leaserHorse care volunteerOther
Feel free to describe or expand on any of the above checked responses.
If you have any additional information you'd like to share with us or questions you'd like to ask? Please do so here.
Legal Disclaimer

The services provided by Withers and Wellness, a subsidiery of Center Stage Athletics, LLC, including Equine Assisted Coaching, are not intended to be a substitute for professional therapy, counseling, or medical treatment. Equine assisted coaching focuses on personal development, self-improvement, and enhancing life skills through interactions with horses. It is designed to offer clients unique insights and experiences for personal growth.

Equine Assisted Coaching should not be construed as mental health therapy, psychological counseling, or any form of clinical treatment. If you are experiencing mental health issues or need medical advice, diagnosis, or treatment, please consult a licensed healthcare professional.

By participating in equine assisted coaching sessions with Withers and Wellness, you acknowledge and agree that:

1. Equine assisted coaching is a personal development tool and not a therapeutic intervention.
2. You understand and accept that Withers and Wellness and its coaches are not licensed therapists or medical professionals.
3. You are solely responsible for seeking appropriate professional medical or psychological advice, treatment, or diagnosis as needed.

Additionally, please be aware that activities involving horses are inherently dangerous. Horses, as prey animals, can exhibit unpredictable behaviors such as bucking, rearing, kicking, and biting. These behaviors can result in serious injury or even death. By participating in equine assisted coaching, you acknowledge and accept the risks associated with working with horses.

Withers and Wellness and its employees, contractors, and affiliates disclaim any and all liability for any adverse outcomes resulting from your participation in equine assisted coaching sessions. Your participation is voluntary, and you assume full responsibility for any risks associated with these activities.

By engaging in equine assisted coaching with Withers and Wellness, you agree to release and hold harmless Withers and Wellness, its owners, employees, and affiliates from any claims, damages, or liabilities arising from your participation.

If you have any questions or concerns about the nature of equine assisted coaching or this disclaimer, please contact us before participating in any sessions.
My signature below indicates agreement with the above legal disclaimer.*

Clear
Please verify that you are human*
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Client Contact Information

If you are NOT the client, please complete the following information.

Coaching Goals

Horse Experience