Prospective Client Information

Date: *

Participants Name: *

DOB: *

Diagnosis/Diagnoses: *

Address: *

Parent/Guardian: *

Address: *

Phone: (Home) *

(Cell): *

(Work): *

Email: *

Medical Insurance: *

Height: *

Weight: *

Seizures: *

Yes

We do have weight guidelines to follow for the sake of our horses, volunteers, and staff. At this time, we are able to accommodate some riders up to 200lbs. We do have a scale on the property that our staff uses to match riders to the appropriate horse and ensure they are within our guidelines. Thank you for understanding.

Does client have physical issues that will prohibit them from riding a horse: *

Can client listen and follow directions: *

Has participant ridden a horse before: *

Yes

How long? How long?

Current/Past Therapy: *

For office use only:

Our office will contact you shortly after receiving this form. How would you like us to get in touch with you? *

Phone

Either

Comments: