Intake Questions Intake Question Please specify whether you are completing this form for an adult (over the age of 18) or for a minor (under the age of 18)This form is for:(Required)Please selectOver the age of 18Under the age of 18INTAKE QUESTIONS FOR ADULTS (over age 18)First name:Contact e-mail: We recognise that some of these questions may be hard to answer in an online form. Please just provide us with as much information as you feel comfortable sharing (without including your last name for now or any other identifying information) to help us help you find the best program for you (whether this is with us or elsewhere). The next stage for working with Healing Hooves will be to book an in person, phone or zoom session during which you will be invited to share more information and ask lots of questions!Please describe your past experiences with horses, dogs and cats (note: no prior experience is required) including any fears.Please provide details of any allergies or special needs.What do you like to do for fun, including hobbies, interests, sports?Is there any specific belief systems that you follow that I need to be aware of?Please describe your presenting concerns, i.e. why you are seeking services?What are your goals or hopes for sessions at Healing Hooves?Please provide details of any diagnoses or assessments performed.Please describe any past counselling experiences you have participated in including the timeline, approach, and your view on its success/ helpfulness, and whether any is ongoing.Please describe the key relationships in your life and the emotional health of these relationships incl. with both parents, siblings, children, extended family, peers, other supports/ influences.Please describe your relationship with sleep, food and work, and any alcohol or drug use.Do you have any concerns with regards to suicide, animal abuse, violence towards self or others, or arson - now, or in the past. If yes, please describe these concerns.Have you experienced or witnessed any form of abuse or other trauma? If yes, please provide some brief information.Has anyone in your home (now or in the past) had any problems with alcohol, drugs, other addictive behaviour or mental health challenges? If yes, please provide some brief information.What worries or concerns do you have about accessing services at Healing Hooves?Any other relevant information you would like to share?INTAKE QUESTIONS FOR MINOR CLIENTS (under age 18)Parent first name:Child first name:Contact e-mail We recognise that some of these questions may be hard to answer in an online form. Please just provide us with whatever information you feel comfortable sharing (without including last names or any other identifying information) to better help us help you find the best program for your child (whether this is with us or elsewhere). The next stage for working with Healing Hooves will be to book an in person, phone or zoom session during which you will be invited to share more information and ask lots of questions!Please provide the age and gender of the child you are seeking support for and whether your child is biological/ adopted/ or foster. (Note: we usually do not recommend equine therapy for children under the age of five).Is there any custody arrangement that we need to be aware of and/or that may impact the consent requirements for accessing services at Healing hooves? Note: In split parenting situations we usually require written consent from both biological parents.Please describe your child’s past experiences with horses, dogs and cats (note: no prior experience is required) including any fears.Please provide details of any allergies or special needs.What does your child like to do, including hobbies, interests, sports?Is there any specific belief systems that your family follows that I need to be aware of?Please describe your presenting concerns, i.e. why you are seeking services for your child?What are your goals or hopes for your child’s sessions at Healing Hooves?Please provide details of any diagnoses or assessments performed.Please describe any past counselling experience you child has participated in including the timeline, approach, how your child responded, your and their view on its success/ helpfulness, and whether any is ongoing. Were/are you involved in these sessionsPlease describe the key relationships in your child’s life and the emotional health of these relationships incl. with both parents, siblings, extended family, peers, other supports/ influences.Please detail and early history of any early separations from attachments (e.g. due to hospitalisations, business travel, split parenting) and how your child responded to these.Please describe the parenting approach you have taken thus far including what has worked/ not worked.Please describe any behavioural or other concerns you see at home, school, or in other relevant environments.Please describe your child’s relationship with sleep and food and whether you are aware of any alcohol or drug use.Do you have any concerns around suicide, sexual abuse, animal abuse, violence towards self or others, or arson with regards to your child now, or in the past. If yes, please describe these concerns.Has your child experienced or witnessed any form of abuse or other trauma? If yes, please provide some brief information.Has anyone in the child’s home had any problems with alcohol, drugs, other addictive behaviour or mental health challenges?How your child feel/s about coming to Healing Hooves?What worries or concerns do you have about accessing services at Healing HoovesAny worries or concerns does your child has/have about accessing services at Healing Hooves?Any other relevant information you would like to share?
