Equine/Animal-Assisted Interest Form Client InformationClient Name *Weight *180lbs - current max # for ridingSexAge *Date of BirthParent / Guardian 1Name 1 *Relationship 1 *Parent 1 Address *CityStateZIP / Postal CodeParent 1 - Phone *Parent 1 - Email *Parent / Guardian 2Name 2Relationship 2Parent 2 AddressCityStateZIP / Postal CodeParent 2 - PhoneParent 2 - EmailHow do you see Equine Assisted / Animal Assisted Services being useful? *0 / 180Which County are you in?DodgeFond Du LacMilwaukeeOzaukeeWashingtonWaukeshaOtherCountyAre you part of any programs?Children's Long-Term Services (CLTS)IRIS (iLife or Premier)Program InterestsTherapeutic Riding (TR)Stabler Moments (SM)AvailabilityTime of DayAM HoursPM HoursDays of WeekMondayTuesdayWednesdayThursdayFridaySelect all that applyBilling InformationAgencyAgency Street AddressCityState/ProvinceZIP / Postal CodeContactContact Email AddressContact PhoneCurrent DiagnosisMental Health Related DSM-VMedical Related ICD10Any current medications or serious illness or allergies to environment, foods, medications etc.?NoYesList of current medicationsWill the client be accompanied by a Support person/Behavioral assistant during session?NoYesSupport Assistant NameSupport Assistant PhoneSupport Assistant Email AddressWhat has been the focus of your treatment? What modalities have you used and what changes have you seen?Please tell us about your work with the above client.Is there any history of client violence directed at people or animals?If yes please explain. SUBMIT
