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Client Waitlist
Please fill out the following to be placed on our waitlist for Horse Assisted Therapy at Paradise Ranch.
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* Indicates required question
Name of client
*
Your answer
Age of client
*
Your answer
Diagnosis or reason for services
Your answer
Are you a military household?
Yes, one of the parents or guardians is a member of the military
Yes, the client is a member of the military
No
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What school does the client attend?
*
Your answer
Are you a returning client?
*
Yes
No
Best days for therapy
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Required
Parent or Guardian Name (where needed)
*
Your answer
Zip Code
*
Your answer
Email
*
Your answer
Address
*
Your answer
Phone number
*
Your answer
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