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HSOTC Veteran Inquiry Form (2023)
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* Indicates required question
Full Name
*
Your answer
Email Address
*
Your answer
Mailing Address (please include city, state, zip code)
Your answer
Phone Number
*
Your answer
Can we leave a message for you at this number?
*
Yes
No
Military Branch of Service
*
Army
Navy
Air Force
Marines
Coast Guard
Caregiver
Other:
Required
Military Status
Active Duty
Reserve/National Guard
Veteran
N/A
Clear selection
How many years did you serve?
*
0-5 years
6-10 years
11-15 years
16-20 years
21-25 years
More than 25 years
N/A
Required
What was your MOS or Specialty? (Mark N/A if no MOS)
*
Your answer
How did you hear about this program?
*
Your answer
What is your reason for contacting us? (Retreat, Individual Therapy, Groups, etc.?)
*
Retreat
Individual Therapy
Therapy Groups
Other:
Required
If interested in 1 day retreat in 2023, which one?
Aug 26, 2023
September 30, 2023
Clear selection
If interested in a retreat, would you be interested in a one-day or two-day retreat?
One day retreat
Two day retreat
Either one- or two-day retreat
Clear selection
Have you ever been diagnosed with PTSD?
*
Yes
No
Do you have any experience with horses?
*
Yes
No
If yes, how many years of experience with horses do you have?
Your answer
Do you utilize a service animal?
*
Yes
No
If yes, are you able to participate in therapy sessions without your service animal?
*
Yes
No
Do you have limited mobility or require the use of a walker or a wheelchair?
*
Yes
No
What pronouns do you use?
she/her
he/him
they/them
Other:
Clear selection
What is your race and/or ethnicity?
*
Your answer
Do you have any allergies?
*
No
Yes
If yes, what are you allergic to?
*
Your answer
Do you have any dietary restrictions?
*
Yes
No
If yes, what are your dietary restrictions?
Your answer
What is your Emergency Contact Number? (no dashes)
*
Your answer
Who is your Emergency Contact Person?
*
Your answer
What relation is this person to you?
*
Your answer
Have you ever tested positve for COVID 19?
*
Yes
No
If yes, what month/year did you test positive for COVID 19?
Your answer
Are you vaccinated and boosted for COVID-19?
*
Yes
No
Vaccinated but not boosted
Prefer not to answer
Other:
Have you ever participated in Equine-Assisted Psychotherapy and Learning programs at Horse Sense Of The Carolinas before?
*
Yes
No
If yes, what program and what year?
*
Your answer
Have you ever participated in Equine-Assisted Psychotherapy and Learning programs at another organization before?
*
Yes
No
If yes, what program, what organization, and what year?
*
Your answer
Thank you for your application. A member of our herd will contact you shortly.
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