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Caregiver, Parent or Social Worker Name

First Last

Child / Youth / Adult Name (Client)

First Last

Client's Pronouns

Client's Age and Date of Birth

Client Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email – Caregiver/Parent/Social worker/Adult Client

Phone – Caregiver/Parent/Social Worker/Adult Client

Background of Client

Briefly describe the challenges that are most significant and reason for seeking services

Choosing Nature Based, Animal Assisted and Equine Facilitated Services

Briefly describe why you believe this approach would be beneficial. Describe the client’s relationship with animals/nature.

School

Online or Distance Learning
Attends in Person
Not in School

Please let us know if the client attends school

Counselling or Wellness Services

Do you require a registered clinical counsellor/registered professional counsellor or a wellness professional for support you are seeking. If you are unsure the team can help guide you.

Funding Support

Would you, your child or youth be interested in group programs?

Yes
No
Maybe

Anything else we need to know ?

Days and times you would be available for a 20 min intake call

Please note it may take up to 2 weeks before we can respond

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Privacy – I understand this information will not be shared beyond the team of facilitators.

Yes
No

I understand this is not therapeutic riding or a traditional riding program.

Yes

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Getting To Know You

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