Date of Birth * MM 1 2 3 4 5 6 7 8 9 10 11 12 / DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / YYYY 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
Age *
Weight (lbs) *
Height (feet, inches) *
Primary/Secondary Diagnosis *
Email *
Phone *
Email *
Phone *
School or Institution presently attending
School Phone
Primary Care Physician's Phone *
Does the participant see a mental health professional? * Yes No
Current allergies, medications, and health concerns /recent surgeries or medical developments: *
Health Insurance Provider
Health Insurance Policy Number
Preferred Medical Facility
Relationship *
Phone *
Relationship *
Phone *
Please provide details:
Please provide details:
Please provide details (e.g. mobility aids used):
Is any adapted equipment used? *
Please describe the participant's current posture, balance, movement, and coordination: *
Does the participant receive physical therapy? * Yes No
Does the participant receive occupational therapy? * Yes No
Does participant have an IEP? * Yes No
Please describe the participant's general attitude & behavior: *
Please describe any perceptual/ balance problems: *
Please describe the current level of the participant's cognitive abilities (age level, multi-step directions): *
Please describe his/her communication style and challenges (verbal, sign, PEC): *
If nonverbal, how are important messages (bathroom break, hunger, thirst, pain, fear) communicated?
Are there any trigger words/actions we should be aware of? *
What are the participant's goals for his/her riding sessions (riding skills, behavioral changes, physical improvements, paying attention)? Please be specific: *
Are there any special considerations we should be aware of (health, precautions, medications, etc)?
Please describe the participant's attitude toward/experience with animals: *
Please describe any previous horseback riding experience: *
Please list other areas of interest or hobbies, sports, recreational activities: *
Do you have any other suggestions or comments for us?
Who would accompany the participant to Flying Manes therapeutic riding classes? *
How did you hear about our program?