EAL Intake Form

Equine assisted learning intake form

* Indicates required field

Name of Client *

First

Last

Age of Client *

Parent's name if under 18 *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Please describe why you are seeking the EAL program? *

Is there trauma in your history? Please describe (i.e. sexual, physical, emotional etc) *

Please list and describe in detail any triggers we should be aware of. *

What is your objective for these sessions? *

Please provide any additional information you believe would help the success of these sessions. *

Submit