New Family Intake Questionnaire
Please take a little time to complete this form. It enables us to serve you and help you understand if Square Peg Ranch is the right place for your family
Email address
This Is Summer by Hollister - A Day at Square Peg Ranch
Your Name
Your answer
What is the name of the child/family member you are looking for services for?
Your answer
What is their age?
Your answer
Tell us a little bit about them?
Your answer
Describe your family's interest in Square Peg and what do you know about us?
Your answer
What is your availability?
Regular Private Sessions are $75 each. Does this cause a financial hardship?
If this does cause a hardship, tell us a little bit about your situation and perhaps we can help?
Your answer
Tell us about any safety or health concerns you have about your family at a working ranch? Note: we DO have a pond with water and there are natural exposure to things like poison oak, ticks and stinging nettles. Allergies? Elopement risk?
Your answer
Does your family currently participate in ABA?
MOST IMPORTANT QUESTION: What are your child's most pleasurable interests?
Your answer
What do you hope that Square Peg can provide for your family?
Your answer
Give us the best way to contact you?
Your answer
Is there anything else we should know about your family that will help us serve you better?
Your answer
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