Patient Information

First Name

Last Name

Email Address

Phone Number

Street Address

City/State

Zip Code

Date of Birth (mm/dd/yyyy)

Insurance Provider

How did you hear about Headin' Home Equine Therapy? How did you hear about Headin' Home Equine Therapy? Google (Search Engine Query) Social Media Personal Referral Other

What are you hoping to be able to accomplish by going through our therapy program? What are your expectations?

Do you have any present or former health or mental diagnoses contributing to your presentation? Do you have any present or former health or mental diagnoses contributing to your presentation? Yes No

If so, please provide a brief description here.

Do you have any current or past substance abuse issues? Do you have any current or past substance abuse issues? Yes No

If so, please provide a brief description here.

Are you currently seeking therapy treatment due to legal charges? Are you currently seeking therapy treatment due to legal charges? Yes No

If so, please provide a brief description here.