Participant Interest Form | Cedar Springs Therapeutic Ranch

Client Information

Client Name *

Weight *180lbs - current max # for riding

Sex

Age *

Date of Birth

Parent / Guardian 1

Name 1 *

Relationship 1 *

Parent 1 Address *

City

State

ZIP / Postal Code

Parent 1 - Phone *

Parent 1 - Email *

Parent / Guardian 2

Name 2

Relationship 2

Parent 2 Address

City

State

ZIP / Postal Code

Parent 2 - Phone

Parent 2 - Email

How do you see Equine Assisted / Animal Assisted Services being useful? *0 / 180

Are you part of any programs?Children's Long-Term Services (CLTS)IRIS (iLife or Premier)

Program InterestsTherapeutic Riding (TR)Stable Moments (SM)

Billing Information

Agency

Agency Street Address

City

State/Province

ZIP / Postal Code

Contact

Contact Email Address

Contact Phone

Current Diagnosis

Mental Health Related DSM-V

Medical Related ICD10

Any current medications or serious illness or allergies to environment, foods, medications etc.?NoYes

List of current medications

Will the client be accompanied by a Support person/Behavioral assistant during session?NoYes

Support Assistant Name

Support Assistant Phone

Support Assistant Email Address

What 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.

Equine/Animal-Assisted Interest Form

Our Partners, Donors, and Supporters

Mailing Address

Ranch Hours

Office Hours

Follow Us

Quick Links

Newsletter Signup

Thank you for subscribing.