Healing Reins Hippotherapy Application

This application is for Hippotherapy (PT/OT/Speech) at Healing Reins. The health professional assigned to you will ask you to complete additional forms and/or releases specific to their practice.
Participant Information
Participant Name *
Date of Birth *
MM
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DD
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YYYY
Age *
Diagnosis: Primary *
Diagnosis: Secondary
Gender *
Height *
Weight *
Primary Phone (please tell us if it is cell or home ) *
Email Address
Street Address *
City *
Zip Code *
School/Institution/Employer Name
Is the Participant a *
Insurance Provider (include secondary, if applicable):
Referring Therapist *
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