New Participant Information Form
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2New Participant Information Form
Please complete this form as accurately as possible so we can best serve your family. All
information is confidential.
Child’s Name_____________________________________________________________________________________________
Child’s DOB_________________ Child’s Age ________ Child’s Gender _______ Child’s ethnicity______________ Is child over 175 lbs.?
Y
N
Parent/Guardian Name________________________________________ Relationship to Child______________________ Legal Guardian
Y N
Address__________________________________________________________ City____________________ State ________ Zip
_____________
Best Contact Number (Cell) __________________________________________
Email_______________________________________________
Emergency Contact: Name________________________________________________ Cell
#___________________________________________
How did you hear about Hope Reins? Circle Internet His Radio Other News Media Word of Mouth
HRR Volunteer
Other______________
Name of Referral Agency ______________________________________ Name of Referral
Person______________________________________
Child has a history of: circle all that apply
Family Divorce
Family Separation
Anxiety
Grief
Loss
Depression
Learning Disabilities
Anger
Conflict
Gangs
Domestic Violence
School Violence Community Violence
Truancy
Personal Substance
Abuse
Parental Substance Abuse Neglect Verbal Abuse Physical Abuse Sexual Abuse Suicide Attempts
Suicide Threats
Adoption
Foster Care
Military Other________________________________
Currently under Care of Therapist/Psychologist:
Name_______________________________________________________________
Any Current
Diagnosis_________________________________________________________________________________________
Assault or Aggressive Behavior
(Describe)__________________________________________________________________________
Does your child have any mental/physical limitations?
(Describe):______________________________________________________
Does your child have any trauma/triggers/phobias?
(Describe);________________________________________________________
Is there any history of animal abuse?
(Describe)____________________________________________________________________
Does your child have any allergies?
______________________________________________________________________________
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