Equine-Assisted Client QuestionnaireThank you for taking the time to complete this form, which will help me provide the best possible coaching and learning experience for you. Please enable JavaScript in your browser to complete this form.Contact InformationPlease check the box that applies.I am completing this form for myself.I am completing this form for my child.I am completing this form for someone else.Client Name *FirstLastEmail *PhoneAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeClient's GenderMaleFemaleIf the client is a minor, please indicate age and grade level.What is your relationship to the client?SelfParentGuardianSpouseOtherIf you are not the client, please complete the following information:Name *FirstLastAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone NumberEmailCoaching GoalsIf you are completing this form as a parent/guardian, please feel free to express both your desire and your child's desires. What led you to book equine-assisted coaching session and/or what do you hope to accomplish?Is the client currently working with any other mental health professionals? *YesNoIf yes, please feel free to briefly describe. Is the client in the care of a doctor and up-to-date on your wellness visits? *YesNoIs the client struggling with any physical health issues? *YesNoIf yes, please feel free to briefly describe.Please check if the clients struggles with or has experienced any of the following:addictive behaviorsalcohol useanxietyangerchronic health issuesdepressiondifficulty concentratingdifficulty sleepingdrug useemotional outburstsfatiguelonelinessrelational conflictsself-harmsuicidal attemptssuicidal thoughtsemotional abusephysical abusedomestic abusesexual abuseself-harm/cuttingtraumatic eventloss of loved onefamily member's addictionbetrayalPlease check if you have been diagnosed with any of the following:anxietydepressionalcohol addictiondrug addictionsmoking addictionporn addictionborderline personality disorderobsessive compulsive personality disorderobsessive-compulsive disordernarcissistic personality disorderpost-traumatic stress disorderHorse ExperiencePlease check all the boxes that reflect your horse experience.No Horse ExperienceLesson Program ExperienceTrail Riding on VacationsCompetitive RiderLove Being Around Horses/AnimalsA Little Scared / Negative ExperienceHorse OwnerHorse LeaserUsed to Ride/Currently Ride a Friend/Family Member's HorsePlease check all that interests you.Learning how to groom a horse.Learning how to ride a horse.Being able to halter and lead a horse out of the field.Connecting with a horse in open spaces.Improving the relationship with my horse.Becoming more confident around horses.Becoming more confident riding horses.Developing a better relationship with my horse.Helping my horse become more confident.Addressing issues with my horse in a different way.Healing and/or recovering from a accident/incident with a horse.Developing life skills through interacting with horses.Caring for my mental health in a better way.How did you hear about us?lisapulliam.comstableminded.usmoretobe.comhorseclass.comHoney Brook StablesWomens Business Connectionfriendfamily membereventFacebookPinterestInstagramLinked InOtherSubmit Login to Client Portal
