Healing Horses: Therapeutic Riding

Serving Children and Adults of All Ages and Abilities in Mid-Missouri

About
Services
Pulse PEMF
Donate
Get Involved
Events
Documents
Contact

Application and Health History

Participant*
First Last
Birthday*
Age*
Height*
Weight*
M or F*
- Male
- Female
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Alternate Phone*
Employer/School*
Employer/School Address*
Street Address Address Line 2 City State ZIP Code
Employer/School Phone*
Parent/Legal Guardian*
First Last
Address (if different from above)
Street Address Address Line 2 City State ZIP Code
Phone (if different from above)
Referral Source
First Last
Referral Phone
Email*
Health History
Please indicate current or past problems in these areas.
- Allergies
- Vision
- Hearing
- Sensation
- Communication
- Heart
- Breathing
- Digestion
- Elimination
- Circulation
- Emotional
- Behavioral
- Pain
- Bone/Joint
- Muscular
- Thinking/Cogniton
Comments
Please explain any of the current or past problems indicatied above
For Therapeutic Participants Only - What medications is your child currently taking, including over-the-counter medications:
For Therapeutic Participants Only - Describe abilities/difficulties in the following areas (include assistance required or equipment needed):
For Therapeutic Participants Only - FUNCTION (i.e. mobility skills such as transfers, walking, wheelchair use, driving/bus riding)
For Therapeutic Participants Only - SOCIAL (i.e. work/school including grade completed, leisure interests, relationships-family structure, support systems, companion animals, fears/concerns, etc):
GOALS (i.e. Why is your child applying for participation? What would you like to accomplish?*
Name
This field is for validation purposes and should be left unchanged.

Δ

Serving & Enriching

At Healing Horses, we serve children and adults of all ages and abilities, and we're dedicated to enriching the lives of individuals with special abilities through equine assisted activities.

501(c)(3) nonprofit organization
PATH Certified Instruction

Let's Talk!

Services offered evenings, Mon. - Thurs. and on Saturdays. Lessons by appointment only.

Healing Horses
573-579-5091
140 Eagle Ridge Trail
Linn MO 65051

Name*
Email*
Message
Email
This field is for validation purposes and should be left unchanged.

Δ

Copyright © 2024 · Website Built by Megaphone Designs