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Hippotherapy, Therapeutic Riding, and Ground Work Only
Name:
_________________________________________________
Address:
_______________________________________________
City:
_____________________State: _________Zip: ____________
Parent/Guardian Name:
___________________________________
Home Phone:
__________________Work Phone:_______________
Cell Phone:
____________________Best time to reach you: ______
Referred by:
________________________Phone: ______________
Disability:
_______________________________________________
Mobility (ie
wheelchair, walks, amount of assistance needed, use of equipment to ambulate, can s/he
stand independently?
Be specific.)
Height:
______________Weight: _________________Age: _______
Mode of communication:
___________________________________
Cognitive abilities:
________________________________________
Social Level:
____________________________________________
Other:
For
office use only. Date
received: ________________
I am interested in
(Check all that apply) _____Hippotherapy _____Therapuetic Riding
_____Ground Work Only