EmailMe Form - Equine-Assisted Therapy Intake Form

Client Information

Full Name *

First Last

Date of Birth *

MM / DD / YYYY

Telephone *

### - ### - ####

Email *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Emergency Contact

Emergency Contact *

First Last

Emergency Contact Relationship *

Emergency Contact Telephone *

### - ### - ####

Medical Information

Primary Care Physician *

First Last

Primary Care Physician Telephone *

### - ### - ####

Are you currently receiving any medical or mental health treatment? *

No

If yes, please describe

Current Medications (including dosage): *

Use N/A if not currently on any medications

Allergies (especially animal-related or environmental): *

Use N/A if not currently on any medications

Physical limitations or mobility concerns:

Have you received any prior therapy? *

No

If yes, what kind and when?

Reason(s) for seeking equine-assisted therapy: *

Specific goals you would like to work on: *

Have you had prior experience with horses? *

Consent & Liability

Please read and agree to each section:

I understand that equine-assisted therapy involves interaction with horses, which carries inherent risks. I agree to follow safety instructions and assume responsibility for any personal injury. I release Horse Sense for Kids Inc/B.N.R. Stables Inc, Michelle H. Madden and staff from liability. *

I agree

By signing below, I confirm that I have read, understood, and agree to the terms of this consent form. *

Clear

Parent/Guardian Signature (if under 18):

Clear