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Client Notes
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Date
MM
/
DD
/
YYYY
Class Time
Time
:
AM
PM
Total Hours
Your answer
Client Name
Your answer
Class Type
Individual
Group
Clear selection
Attendance
Attended
Refused to Attend
Excused Absence
Unexcused Absence
Clear selection
Horse Used
Your answer
Wellness Focus
Physical
Social
Intellectual
Emotional
Spiritual
Occupational
Activity Focus
Red (self-regulation, survival)
Orange (Healthy Relationships, Social)
Yellow (Self-esteem, Willpower)
Green (Emotional Regulation, Love)
Turquoise (Expression, Communication, Respect)
Blue (Intuition, Focus, Responsibility)
Purple (Peace, Joy, Insight, Independance)
Objective 1
Your answer
Objective 2
Your answer
Objective 3
Your answer
Points
1
2
3
4
5
6
7
8
9
10
N/A
Respect
Engagement
Horse Interaction
Peer Interaction
Listening
Self Regulation
Follows Directions
Boundaries
Stays on Task
Effort to Learn
Self-Confidence
Personal Energy
1
2
3
4
5
6
7
8
9
10
N/A
Respect
Engagement
Horse Interaction
Peer Interaction
Listening
Self Regulation
Follows Directions
Boundaries
Stays on Task
Effort to Learn
Self-Confidence
Personal Energy
Clear selection
Session Summary
Your answer
Objective Met
Yes
No
Working On
Clear selection
Payment Made
Your answer
Next session ideas
Your answer
E-Signature of Facilitator
Your answer
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