LEAD with Horses · New Student/Client Intake ADULT

Contact Information

Name *

First Name

Last Name

Preferred name/nickname

Date of Birth *

(mm/dd/yyyy)

Where did you hear about LEAD with Horses? *

Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Email *

Verify Email *

Phone *

Mobile phone provider

Background

Have you experienced any significant life changes or stressful events? *

Yes

No

Please explain

Describe any concerns you have about your own behavior or experiences *

Please note where (e.g. school, home) &/or under what circumstances behaviors occur

Describe how you get along with others *

Please list your strengths and talents *

What do you hope to gain from participation in this program? *

Do you have any previous experience with horses? *

Yes

No

Please explain

Medical

Are there any medical conditions present that need to be considered when you participate in equine assisted programs? *

Yes

No

Please explain

Do you have a physical or mental health diagnosis? *

Yes

No

Please list/explain

Current Medications, if any

Current Medications, if any Copy

Do you have any allergies? *

Yes

No

Please list

Do you have any dietary restrictions? *

Yes

No

Please list

Please note anything else you want us to know or questions you may have

Emergency Contact Information

Contact Name *

First Name

Last Name

Contact Email *

Verify Email *

Contact Phone *

Demographics

Please share some additional information. This will help inform program outreach to best meet our community's needs and will assist us with grant funding.

LEAD with Horses does not discriminate on the basis of actual or perceived race, color, creed, religion, national origin, ancestry, citizenship status, age, sex or gender, gender identity or expression (including transgender status), sexual orientation, marital status, military service and veteran status, physical or mental disability, genetic information, or any other characteristic protected by applicable federal, state, or local laws and ordinances.

Please share your ethnicity *

African-American

Asian

Caucasian

Latino or Hispanic

Native American

Native Hawaiian or Pacific Islander

Two or More

Other/Unknown

Prefer not to say

How many children in your household? *

None

1

2

3

4

5 or more

Prefer not to say

What is your household income? *

0-$20,000

$20,000-$40,000

$40,000-$60,000

$60,000-$90,000

over $90,000

Prefer not to say

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New Student/Client Intake ADULT

This is intake paperwork for registered/enrolled clients, and does not reserve a spot in a class or in private therapy.

Contact Information

Background

Medical

Emergency Contact Information

Demographics