Adirondack Equine Assisted Psychotherapy Intake Form printable pdf download

Shannon Myles, LCSW c/o Haven Oaks Farm 46 Reynolds Rd. Fort Edward, NY 12828

Phone: (518) 573-0239 Fax: (518) 747-2194

Thank you for your interest in Adirondack Equine Assisted Psychotherapy. Please complete the

following form and contact me with any questions. Thank you.

Date: ______________

Source of Referral:_________________________Phone Number:_______________________

Address:____________________________________________Fax Number:_______________

Primary Therapist:__________________________Phone Number_______________________

Address:__________________________________Fax Number:_________________________

Case Worker:_______________________________Phone Number:_____________________

Address:__________________________________Fax Number:_________________________

Emergency Contact:_________________________Phone Number_______________________

Identifying Information:

Client Name:_________________________Preferred First Name:_______________________

Address:_____________________________________________________________________

Gender:___________Marital Status:_______________Age:_____Date of Birth:_____________

Parent/Guardian:_______________________Phone Number:___________________________

Reason for Referral:___________________________________________________________

____________________________________________________________________________

Pertinant History: (history of symptoms; precipitants; abuse; self-injurious behavior; level of

functioning)___________________________________________________________________

____________________________________________________________________________

Adirondack Equine Assisted Psychotherapy Intake Form