501(c) (3) non-profit corporation and a member center of North American Riding for the Handicapped Association (NARHA)

7580 Rivertown Road Fairburn, GA 30213

678-296-9693

Fax: 678-288-7870

Mental Health and Learning Program

Dear Prospective Client,

These forms are made available to you to help your team develop a sound, informative treatment plan. The more we understand about you the more we will be able to help you; feel free to skip any questions you may find too uncomfortable.

We know these forms take time and effort on your part. Completing them ahead of time will give us plenty of time to focus on your immediate concerns during your scheduled appointment and/or meet with your mental health professional for supporting documents.

Sincerely,

Sara Carter

Please fill out all questions on the following forms. If the sheet/question does not apply to you, please indicate it next to the question. Sign any area that a signature is required, then you can mail, fax, or email your paperwork into the office. After we’ve had time to process your paperwork, we will set up an appointment.

There is no need to supply any insurance information to us. Payment is due at the time of service; we will give you a super bill for reimbursement from your insurance company.

Personal Information:
Name: D.O.B: Phone:
Address:
Physician:
Medical Facility:
Current Medications:
In the event of an emergency, contact:
Name/number: Relation:
Name/number: Relation:
Name/number: Relation:

In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, I authorize Haven Hills to:

1.  Secure and retain medical treatment and transportation if needed; and

2.  Release Client records upon request to the authorized individual or agency involved in the medical emergency treatment.

Consent Plan:
This authorization includes x-ray, surgery, treatment, hospitalization, medication, and any treatment procedure deemed “lifesaving” by the physician. This provision will only be invoked if the persons above are not able to be reached.
Consent Signature: Date:
Client, Parent or Legal Guardian:
Non-Consent Plan:
I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency. In the event emergency treatment/aid is required, I wish the following procedures to take place:
Consent signature: Date:
Client, Parent, or Legal Guardian:
Today’s date:
Personal Information:
Client name: Age: Gender:
Date of Birth: Marital Status:
Parent/guardian Name: Age: Gender:
Partner’s Name: Age: Gender:
Address:
Home Phone: Cell Phone: Work phone:
Number of children: Ages/Gender:
Education/Occupation:
Highest level of education:
Highest level of education of parent/guardian:
Present Occupation: Company Name:
Main occupation during last 5 years:
General Information:
How did you hear about us?
Problems you need help with:
Describe your education:
Describe your living condition:
How much have you worked in the past 2 years?
Describe any psychological problems you have had (e.g. periods of depression, anxiety, fears, phobias, anger, confusion, etc…)
Have there been any deaths in you immediate/extended family?
How long ago?
Who?
Other family/friends/pet deaths:
When were you last seen by a physician?
Name of physician?
Phone:
Please list any major health problems for which you have received treatment:

Do you or your family members currently have or have ever had any of the following (check all that apply)

SELF FAMILY CHILDREN

Heart problems
Cancer
Anxiety
Stroke
Eating disorder
Alcohol/drug abuse
Legal problems
Learning disability
Depression
Other

List any medications you are now taking (prescriptions and/or over the counter):

Have you or your child ever received psychological help or counseling before:

If so, please describe:

Have you ever been assaulted?

Have you/your child ever witnessed abuse/violence within your family?

Please list everyone currently living in your home:

Name: / Age: / Relationship / Occupation

Please circle any of the following that is a concern to you or your child:

Nervousness / Sexual problems / Finances / Sleep problems / Headaches
Ambition / Loneliness / Career / Children / Road rage
Impulsiveness / Depression / Suicidal thoughts / Anger / Stress
Tiredness / Hyperactivity / Low self esteem / Marriage/relationships / Defiant behavior
Fighting / Drug/alcohol use / Fears / Separation / Self-control
Work/school / Legal problems / Nightmares / Concentration / Health problems
Unhappiness / Bed wetting / Stealing / Shyness / Divorce
Friends / Relaxation / Memory / Making decisions / Education/grades
Temperament / Sexual abuse / Perfectionism / Lying / Physical abuse
Bowel troubles / Being a parent / Bizarre thoughts / Stomach problems / Gambling
Binge eating / Eating too much / Eating too little / Panic / obsessiveness

Please circle any of the following strengths that would describe yourself or your child:

Confident / Dependable / Decisive / Intelligent / Spiritual
Ambitious / Hard worker / Sensitive / Responsible / Communicative
Creative / Sympathetic / Organized / Logical / Understanding
Likeable / Fun-loving / Respectful / Sympathetic / Loyal
Funny/humorous / Attractive / Passionate / Ethical / Good listener
Compassionate / Loving / Decent / Athletic / Caring

Please use the chart below to describe your use of drugs/alcohol use:

Age first used: / Frequency of use: / Last used:
Tobacco
Alcohol
Marijuana
Cocaine
Crack
Crank
Amphetamine/speed
Hallucinogens
Coffee
Other

Section A: Protective Attire

1.  I am hereby advised to always wear hard-soled, fully enclosed shoes or boots and socks to protect feet and long pants to protect legs while working around or interacting with horses.

Section B. The nature and Physical Character of the Horse

Domesticated, well-trained horses are usually obedient, docile and affectionate. However, it is important to understand that their survival instincts are what have allowed the horse to survive from prehistoric times to the present day.

1.  I am advised that horses are unpredictable by nature, with minds of their own, as are all animals both domestic and wild. The horse is often somewhat high strung or nervous by nature. Horses are extremely strong and physical powerful. Horses are extremely heavy weighing from 600-1300 pounds on the average. The characteristics deserve a human beings utmost respect.

2.  I am advised that when a horse is frightened, angry, under stress or feels threatened, it is the horse’s instinct to jump forward or sideways, to run away from danger at a trot or gallop of speeds up to 35 miles per hour.

3.  I am advised that if a horse is frightened or feels threatened from behind, the horse may kick straight back, sideways in either direction or even forward with either or both hind legs with tremendous force.

4.  I am advised that if a horse is frightened or feels threatened from above or from his/her back, he/she may hunch the back and buck in a way that could throw a rider to the ground with tremendous force. A fall from a horse will usually be from a height of 3-6 feet.

5.  I am advised that if a horse is frightened or feels threatened from the front, the natural reaction may be to rear up with both front legs, strike with one or both front legs, bite with teeth, throw the head up or from side to side, or run directly over whatever he/she fears in front of him/her.

6.  I am advised that a human must always approach a horse calmly and quietly with caution, preferably to the horse’s shoulder or lower neck, talking soothingly to the horse.

7.  I am advised that loud and/or sudden unexpected movements, dropping of objects near a horse, approaching vehicles or animals or people, ill-fitting equipment or physical pain can provoke a domesticated horse to react according to natural, protective instincts.

8.  I am advised the first signs of anger or fear in a horse are the sudden tensing of the muscles of the body, possibly laying the ears flat back against the head, or quickly tossing or raising the head, or sudden snorting through the nostrils accompanying at least one other warning sign.

9.  I am advised that a horse can see independently with each eye, actually looking in one direction with one eye and another direction with the other eye. The horse can also focus both eyes on one object somewhere in front of him/her. Typically the direction the ear is point will tell and observer where the eye is looking on the same side.

10.  I am advised that a horse has to blind areas around which he/she cannot see. Those areas are directly behind the horse and directly in front. When a horse has his/her head lowered to the ground, the spot directly at the end of the nostrils is a blind area. This is the reason it is best to approach a horse close to the shoulder and never to surprise a horse from the rear, or to reach first for the horse’s mouth.

11.  I am advised that while a horse is a very sure footed by nature, horses my accidently step on a n object such as a human’s foot when the horse is balancing or turning around, When a horse is worked on unstable ground or slippery grass or footing, the horse could fall down injuring the horse, rider, and/or handler.

I/We hereby indemnify and agree by this signing to release Haven Hills Equestrian Center, Inc., Sara Carter, and all associated persons from liability for any accident or injury sustained by me, my employees, heirs, dependents, or guests. It is understood that this includes landowners, trainers, independent contractors, any employees and any other individual related to the ownership or management of the horse facilities, including but not limited to, Sara Carter. I am also aware that “UNDER GEORGIA LAW, AN EQUINE ACTIVITY SPONSOR OR EQUINE PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO OR THE DEATH OF A PARTICIPANT IN EQUINE ACITIVITIES RESULTING FROM THE INHERENT RISKS OF EQUINE ACTIVITIES, PURSUANT TO CHAPTER 12 OF TITLE 4 OF THE OFFICIAL CODE OF GEORGIA ANNOTATED.”

I have read and do understand the above warnings concerning protective attire, the nature and physical character of the horse, and Georgia law.

Participant or Parent/Guardian: Date:

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