Participant Intake Form
How to get enrolled at Hearts & Horses: Please fill out the Participant Intake Form below.
Name of Participant:
First Name
Last Name
What program are you interested in?
Changing Leads
Therapeutic Riding
Therapy Services (Hippotherapy - Service Provided by an OT or PT)
Veteran's Program (please fill out the form on the
Veterans page
)
Riding in the Moment
Are there any funding sources we need to verify?
FAPT/DHS Referrals, Foothills Gateway, Envision, etc.
Date of Birth
Gender
Male
Female
Other
Decline To Answer
Other (Gender)
Weight
Height
Please enter your height as a decimal amount. Ex. 5'3" would be 5.3.
Employer or School District
How Did You Find Our Services?
Please select...
Autism Research Study Publicity
Friends or Family
Social Media
Drive By
Website
Professional Reference
Other
Other/Referral Details
Contact Information:
Relation to Participant
Self
Parent
Caregiver
Please provide information for a parent or caregiver instead of self if participant is a minor.
Phone Number
Email Address
First Name
Last Name
Relation
Please select...
Advisor
Aunt
Boyfriend
Brother
Brother in Law
Caregiver
Case Worker
Child
Cousin
Coworker
Daughter
Daughter in Law
Employee
Employer
Family
Father
Father in Law
Fiance
Financial Partner
Friend
Girlfriend
Grandchild
Granddaughter
Grandfather
Grandmother
Grandparent
Grandson
Guardian
Husband
Mother
Mother in Law
Nephew
Niece
Other
Parent
Partner
Sister
Sister in Law
Son
Son in Law
Spouse
Step Daughter
Step Father
Step Mother
Step Son
Uncle
Wife
Gender
Male
Female
Other
Other (Gender)
Phone Number
Email Address
Employer or School
Mailing Address:
Street
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
County
Please select...
Larimer
Weld
Boulder
Other
Country
Please select...
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos ( Keeling ) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Côte d ' Ivoire
Croatia ( Hrvatska )
Cuba
Cyprus
Czech Republic
Congo ( DRC )
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands ( Islas Malvinas )
Faroe Islands
Fiji Islands
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia, Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé and Prìncipe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Kitts and Nevis
St. Lucia
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Viet Nam
Virgin Islands ( British )
Virgin Islands
Wallis and Futuna
Yemen
Zambia
Zimbabwe
Do you have another address to enter? (Physical Address, Work Address, etc.)
Yes
No
Other Address Type
Please select...
Physical Address
Work Address
Street
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Country
Please select...
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos ( Keeling ) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Côte d ' Ivoire
Croatia ( Hrvatska )
Cuba
Cyprus
Czech Republic
Congo ( DRC )
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands ( Islas Malvinas )
Faroe Islands
Fiji Islands
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia, Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé and Prìncipe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Kitts and Nevis
St. Lucia
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Viet Nam
Virgin Islands ( British )
Virgin Islands
Wallis and Futuna
Yemen
Zambia
Zimbabwe
Participant Information:
What type of goals is the participant prioritizing now?
Please select...
Social emotional skills
Physical skills
Riding or horsemanship skills
Cognitive skills
Why is the participant seeking services at Hearts & Horses?
Presenting Problems/Concerns?
What is the participant's previous riding experience?
Please select...
None
Minimal
Moderate
Extensive
With Assistance
Independent Riding
To select multiple options, hold down "Control" key (PC) or the "Command" key (Mac) on your keyboard.
Would the participant be comfortable in a group setting?
Yes
No
If no, please explain
What days/times would be available for a weekly 1hr lesson? (Lessons occur M-F 9am-5:30pm, Saturday 9am-1pm, closed on Sundays)
Primary Diagnosis (Participant)
Please select...
Acute Flacid Myelitis
Alzheimer's
Anxiety
Aphasia
Arthritis
Asperger Syndrome
Attachment Disorder
Attention Deficit Disorder
Attention Deficit Hyperactivity Disorder
Auditory Processing Disorder
Autism
Bereavement
Bipolar Disorder
Cardiovascular
Celiac Disease
Cerebral Palsy
Cerebrovascular Accident
Chron's Disease
Depression
Developmental Delay
Down Syndrome
Dyslexia
Dysphagia
Emotional Disorder
Emotional Needs
Executive Functioning Disorder
Fetal Alcohol Syndrome
Hearing Impairment
Highly Gifted
Hydrocephalus
Hyper Lordosis
Hypotonia
Isodicentric 15-Chromosonal Disorder
Juvenile Pilocytic Astrocytoma
Learning Disabilities
Mitral Valve Prolapse
Multiple Sclerosis
Muscular Dystrophy
Neurodevelopmental Disorder
Obsessive Compulsive Disorder
Oppositional Defiant Disorder
Osgood Schlatter's Disease
Parkinson's Disease
Peter's Anomoly
Phelan-McDermid
Physical Disabilities
Post Traumatic Stress Disorder
Prader Willi Syndrome
Pre-Mature Birth
Rhetts Syndrome
Schitzoaffective Disorder
Schizophrenia
Seizure Disorder
Sensory Processing Disorder
Smith-Lemli-Opitz Syndrome
Spastic Diplegia
Spina Bifida
Spinal Cord Injuries
Spinal Stenosis
Stroke
Suicidal
Tinnitus
Trauma
Traumatic Brain Injury
Visual Impairment
Other
Secondary Diagnosis (Participant)
Please select...
Acute Flacid Myelitis
Alzheimer's
Anxiety
Aphasia
Arthritis
Asperger Syndrome
Attachment Disorder
Attention Deficit Disorder
Attention Deficit Hyperactivity Disorder
Auditory Processing Disorder
Autism
Bereavement
Bipolar Disorder
Cardiovascular
Celiac Disease
Cerebral Palsy
Cerebrovascular Accident
Chron's Disease
Depression
Developmental Delay
Down Syndrome
Dyslexia
Dysphagia
Emotional Disorder
Emotional Needs
Executive Functioning Disorder
Fetal Alcohol Syndrome
Hearing Impairment
Highly Gifted
Hydrocephalus
Hyper Lordosis
Hypotonia
Isodicentric 15-Chromosonal Disorder
Juvenile Pilocytic Astrocytoma
Learning Disabilities
Mitral Valve Prolapse
Multiple Sclerosis
Muscular Dystrophy
Neurodevelopmental Disorder
Obsessive Compulsive Disorder
Oppositional Defiant Disorder
Osgood Schlatter's Disease
Parkinson's Disease
Peter's Anomoly
Phelan-McDermid
Physical Disabilities
Post Traumatic Stress Disorder
Prader Willi Syndrome
Pre-Mature Birth
Rhetts Syndrome
Schitzoaffective Disorder
Schizophrenia
Seizure Disorder
Sensory Processing Disorder
Smith-Lemli-Opitz Syndrome
Spastic Diplegia
Spina Bifida
Spinal Cord Injuries
Spinal Stenosis
Stroke
Suicidal
Tinnitus
Trauma
Traumatic Brain Injury
Visual Impairment
Other
To select multiple options, hold down "Control" key (PC) or the "Command" key (Mac) on your keyboard.
Medical History
Please provide all relevant information.
Has participant had (or is currently having) seizures? If so, please describe.
Please provide type and date of last incident if applicable.
Does participant use any assistance devices?
Including wheelchair, cane, communication devices, etc.
I certify that the information supplied, to the best of my knowledge, is up to date and accurate.
Signature of participant, parent or guardian (if participant is a minor)
Date
A copy of this response will be sent to: