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Warriors & Horses Application Form
General Information
Name
*
First Name
Last Name
Birthdate
(mm/dd/yyyy)
Email
*
Verify Email
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Primary Phone
*
Secondary Phone
Preferred Method of Contact
*
Phone Call
Text - Primary #
Text - Secondary #
Email
Marital Status
Do you have children?
Yes
No
Gender
If you have pronoun preferences, please leave us a note at the end of this application.
Male
Female
Trans*
Other
Emergency Contact Name
*
First Name
Last Name
Relationship to you:
Emergency Contact Address
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Emergency Contact Phone
*
Service Information
Service Information Copy
Service Status
*
select one
Active
Retired
Discharged
Reserve
First Responder
Not Applicable
Service Branch
*
select one
Air Force
Army
Coast Guard
Marines
National Guard
Navy
Other
Service Era
*
select one
Post 9/11
Cold War
Desert Storm
Vietnam
Korea
WWII
Other
If you answered "Other" in any field above, please elaborate below:
If you answered "Other" in any field above, please elaborate below: Copy
Your Symptoms
While Alatheia Riding Center is not a mental health facility, having some insight into our clients’ state of mind can help our staff design meaningful programming. Please elaborate on any answers in the section below. Your responses are strictly confidential.
Are you currently working with a mental health therapist?
select one
Yes
No
If so, please name below.
So we can better serve you, will you sign a Consent to Release Information for that therapist?
select one
Yes
No
Please select any of the following that are true for you:
*
I experience nightmares or flashbacks of a traumatic experience
I avoid situations that remind me of a traumatic experience
I have angry outbursts
I have difficulty focusing
Sometimes I feel hopeless, numb, or bad about myself or others
I have had thoughts of suicide
I have had intense feelings of guilt or shame
I don’t feel enjoyment and/or have no interest in maintaining relationships with friends/family
I feel anxious
I am often on high alert/scanning my environment
I feel depressed
I have been diagnosed with PTSD or I believe I have PTSD
Other (please desribe below)
What else would you like to share with us?
Substance Use
Many applicants have used or are using/abusing alcohol, prescription medications or drugs. Disclosing substance use WILL NOT disqualify you. Understanding your pattern of use will help our staff meet you where you are now in your journey and factor that into your experience at Alatheia. Your responses are strictly confidential.
Please describe your current pattern of using alcohol, medication, or other drugs:
How much does your pattern of use impact your daily life currently?
Medications
It is helpful to understand what prescription medications you are currently taking for mental health or physical issues. Please list below.
Prescribed Medications
Please list your prescribed medications.
Is there anything else you'd like to share with us?
Daily Function and Goals
Please describe your abilities and/or challenges in the following areas:
Physical Function
*
Mobility, stamina, adaptive equipment used, areas of pain, etc.
Psycho/Social Function
*
Family/friend relationships, work/school, support systems, concerns/fears, etc.
Goals
*
Physical, social or equine-related: what do you hope to get out of your experience with Alatheia?
Horse Experience and Interests
Have you had experiences with horses before?
*
select one
Yes, many times
Yes, some
No
If yes, briefly describe your horse experience.
If yes, briefly describe your horse experience. Copy
Height & Weight
This information aids in horse selection
Photo Release, Firearm Policy & Signature
I (your response) consent to and authorize the use and reproduction by Alatheia Riding Center of any and all photographs and other audio/visual materials taken of me for promotional material, educational activities or other program use.
*
I Do
I Do Not
Alatheia Riding Center does not permit firearms of any kind to be brought onto the premises. Clients may leave their firearm inside their locked personal vehicle while participating in services.
*
I understand and agree to comply
By typing my full name below, I declare that all information given is true and correct.
*
