HPM Sessions - Intake Form

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HPM Sessions - Intake Form - 2024

HPM offers 1-1 sessions at no cost to kids and teens in a life crisis.

We are open Wednesdays - Saturdays | 90 minute one-on-one sessions.

HPM Session Season 2024
Session One - Registration opens April 3rd

Session Block - April 24th - June 1st

Session Two - Registration opens May 22nd

Session Block - June 12th - July 20th

Session Three - Registration opens July 10th

Session Block - July 31st - Sept 7th

Session Four - Registration opens August 28th

Session Block - Sept 18th - Oct 19th

Once registered a session coordinator will call you to go over your intake form and place your child with the best possible time, date and mentor.

Participant (Child / Teen) Information

Please share the following information regarding the child or teen who is considering participation

Child/Teen's First Name *

Child/Teen's Date of Birth *

YYYY

Child/Teen's Age *

Child/Teen's Ethnicity *

Black or African America

Hispanic or Latino

White

Asian

Native American

Multiple Race

Other

Child/Teen's Gender *

Does your child/teen have any medical conditions? Allergic reactions? Epipen needed? On medications?

Family Information

Please share the following information regarding the child or teen's family

How many immediate family members are in your household? * *

Please list names and ages of siblings and any other household members *

Parent/Caregiver Contact Information

Parent/Caregiver First Name *

Parent/Caregiver Last Name *

Is the above adult the child/teen's legal guardian? *

Yes

If answer to above question is no, please describe your relationship with the child/teen.

Parent/Caregiver's Home Phone Number *

Parent/Caregiver's Mobile Phone Number *

Parent/Caregiver's Email

Street Address *

City *

State *

County *

Zip/Postal Code *

Emergency Contact First Name (please choose someone who would be locally accessible in case of emergency at the ranch) *

Emergency Contact Last Name *

Emergency Contact Phone Number *

Child/Teen has a history of: *

ADHD

Adoption

Anxiety

Anger

Bullying

Community Violence

Conflict

Depression

Domestic Violence

Emotional Abuse

Family Divorce

Family Separation

Foster Care

Frequent Relocation

Foster care

Gangs

Grief

Labor Trafficking

Learning/Cognitive/disability

Loss

Military

Neglect

OCD

ODD

Parental Death

Parental Substance Abuse

Personal Substance Abuse

Physical Abuse

Physical Limitations / Med Dx

PTSD

School Violence

Self Harm

Sex Trafficking

Sexual Abuse

Suicidal Attempts

Suicide Ideation

Suicide Threats

Traumatic experiences

Truancy

Verbal Abuse

Other:

Required

Child/Teen currently struggles with: *

ADHD

Anger

Anxiety

Conflict

Depression

Grief

Depression

Grief

Learning Disability(s)

Low self esteem

OCD

ODD

PTSD

Self harm

Suicidal Ideation/Threats

Suicide Attempts

Other:

Required

Is your Child/Teen currently in crisis *

Yes

Maybe

Not Sure

How long has the child/teen been struggling with these issues? *

Child/Teen Potential Areas of Development

HPM's programs are designed to help children grow and develop emotionally, spiritually, physically, relationally.

Please identify the top five (5) outcomes you hope to see in the participant *

Boundaries

Comfort

Communication

Confidence

Empathy

Improved Participation in School/Home Life

Improved Relationships

Improved self talk/feelings

Leadership

Listening skills

Respect (self/others)

Respite

Responsibility

Self control

Self expression

Sense of belonging

Sense of purpose

Sense of safety

Sense of Value/Worth

Social Skills

Trust

Other:

Required

Child/Teen Strength and Character traits (i.e. child is very compassionate) *

How did you hear about HPM *

Church

Social Media / News / Radio

Online

Word of Mouth

Referral / Partner

Therapist/Counselor

HPM Volunteer/ Staff

Other:

Do you identify with a place of worship? If so, where? *

Please list referral Agency and person if applicable

Child/Teen currently under the care of Therapist/Psychologist (name):

Please list any current diagnoses

Please describe any physical/mental limitations

Please describe any past or present assault/aggressive behavior

Is there a history of animal abuse? *

Yes

Please share anything you feel would be helpful in understanding the child/teen's situation *

Please state your name below, indicating that you verify the above information is true and accurate *

Program Information and Availability

Hitching Post Session Season begins: February through mid-November

Sessions are scheduled at the following days & times: Wednesdays - Saturdays, 90 minute session times are available.

Once registered, a session coordinator will call you for an intake interview so that we fit your needs with the best possible time, date and mentor.

Please indicate your availability for participation *

Wednesday

Thursday

Friday

Saturday

Required

Are you willing to be placed on the waitlist *

Yes

Maybe

Are you willing to have your child/teen be a part of non-horse activities? *

Yes

Maybe

What Session are you signing up for *

Session 1: April 24th - June 1st

Session 2: June 12th - July 20th

Session 3: July 31st - Sept 7th

Session 4: Sept 18th - Oct 19th

Thank you for filling out this form. What to expect:

A session coordinator will call you for an intake interview so that we fit your needs with the best possible time, date and mentor.

HPM Waiver - HPM Waiver

ALL CHILDREN and ALL ADULTS coming onto the premises must have a completed waiver. Each adult must have a completely separate form.

After you submit this form please head back to our website and fill out the Waiver Form found on the program page.

Thank you!

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