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Potential Client Intake Form
Email *
First & Last Name of Potential Client *
Gender *
Primary Contact Name *
Relationship *
Phone Number *
Age *
Height (Guesstimate) *
Weight *
For the safety of our staff and horses, we have a 200lb weight limit
Type of Service Seeking *
Required
Are you seeking a specific therapist? If so, who?
Are you currently seeing this therapist at a different location?
Clear selection
Diagnoses *
Medications *
Implanted Devices (Shunt, G-Tube, Broviac, etc.)
Mobility *
Required
Other Devices
Allergies *
Communication *
Required
Can potential client follow one step directives such as stop and go? *
Does the client currently have or had in their past, any of the following: *
***Please check all that apply and do not skip over this section***
Required
School/Employment/Day Program *
Grade
Are you approved for therapy through (DDD) Division of Developmental Disabilities *
Empowerment Scholarship or Grant? *
Are you able to attend a week day, day time therapy session? *
Three Things That Bring Pleasure *
Three Things That Bring Distress *
Thank you for your interest in Barn Yard Equine! We will be in touch shortly!
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