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Equine Assisted Therapy Needs Assessment Survey
The aim of this survey is to identify a need for services in our community that support and nurture the overall mental health of adults, children and families. This survey will be utilized in developing services to meet these identified needs.
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Email
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Your email
Glade Run Adventures provides hands-on experiences with horses and natural environments that are aimed at meeting the emotional and behavioral goals of individual participants. Equine Assisted Therapy services are non-mounted (do not include horseback riding).
I have an interest in participating in equine assisted therapy for myself
Yes
No
Maybe
Clear selection
I have an interest in having my child participate in equine assisted therapy
Yes
No
Maybe
Clear selection
I would like individual sessions
Yes
No
Maybe
Clear selection
I would like group sessions
Yes
No
Maybe
Clear selection
I would like to participate as a part of family therapy
Yes
No
Maybe
Clear selection
I have an interest in equine assisted therapy GROUPS that focus on:
No Interest
Some interest
A Lot of Interest
Wellness / Mindfulness
Reducing Anxiety
Building Healthy Relationships
Social Skill Development
Increased Communication Skills
Reduced Depression
Increased Self-Esteem
Increased Trust
Overcoming Fear
No Interest
Some interest
A Lot of Interest
Wellness / Mindfulness
Reducing Anxiety
Building Healthy Relationships
Social Skill Development
Increased Communication Skills
Reduced Depression
Increased Self-Esteem
Increased Trust
Overcoming Fear
Clear selection
A significant challenge that I would have in participating in equine assisted therapy would be:
Transportation to/from Zelienople
Affording a Copay
Fear of Horses
Other:
When would be the best time(s) for you to be able to participate in groups?
Mondays or Fridays after school (3:00 pm - 4:00 pm)
Wednesdays during the day
Weekends
Other:
Your Name
*
Your answer
Name of your child, first and last (if completing survey for your child)
Your answer
Child's age (if completing survey for your child)
Your answer
Preferred Pronouns
She/Her
He/His
They/Them
Areas of Mental Health Concern:
Anger / Aggression
Anxiety
Autism Spectrum Disorders
Behaviors
Depression
Developmental Disabilities
Hyperactivity / Impulsivity
Lack of attention
Post-Traumatic Stress
Risk of harming self or others
Other:
Phone Number
Your answer
Insurance Carrier
Your answer
City / Town of Residence
Your answer
Please list any additional comments / questions that you may have
Your answer
For more information about Equine Assisted Therapy at Glade Run Adventures, please visit our website at
www.gladerunadventures.org
or contact Julie Whalenmayer, Adventures Program Director at
JWahlenmayer@gladerun.org
or (724) 452-4453 ext. 1236.
A copy of your responses will be emailed to the address you provided.
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