Prospective Client Information

Date: *
 
Participants Name: *
 
DOB: *
 
Address: *
 
Parent/Guardian: *
 
Address: *
 
Phone: (Home) *
 
(Cell): *
 
(Work): *
 
Email: *
 
Medical Insurance: *
 
Height: *
 
Weight: *
 
Seizures: *
 Yes
 No
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
 No
 How long?
Current/Past Therapy: *
 
Preference: *
 Sunday
 Monday
 Tuesday
 Wednesday
 Thursday
 Friday
 Saturday
For office use only:
Comments: