Please take a moment to fill out this brief questionnaire to help give us more information about your child and how we can best work together.

Name

First Name

Last Name

Childs Name

First Name

Last Name

Relationship to child

Date of birth

11/11/1111

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Phone

(###)

###

####

Does your child have a current IEP for speech and/or language?

Y/N

Does your child attend speech therapy at an additional site?

Y/N

If yes, where?

Please check all areas of communication for which your child receives therapy:

Receptive language

Expressive language

Articulation/Phonology

Fluency

Pragmatic/Social language

Briefly describe your primary communication concerns

Are there any cognitive, physical, or behavioral reasons why your child may not be safe around horses with adult supervision?

Y/N

If yes, please describe the nature of the caution and/or pertinent diagnoses

Additional comments