Equine/Animal-Assisted Interest Form NAME *EMAIL *PHONE *DOBSEXWEIGHT180lbs - current max # for ridingADDRESSPARENT / LEGAL GUARDIAN NAME (S) - If applicableHow 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)Comprehensive Community Services (CCS)Wraparound (WRAP)Children community options program (Children's COP)Current Diagnosis (Mental Health Related DSM-V / Medical Related ICD10)Any current medications or serious Illness or Allergies to environment, foods, medications etc.?NoYesPlease list:Presenting IssuesAcademicBehavioralFamilySocialRelationalLife SkillsSocial SkillsVocational SkillsSelf-esteemAttitudeOtherPlease listSUBMIT
