JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
HSOTC Veteran Inquiry Form 2022
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name
*
Your answer
Email
*
Your answer
Address
Your answer
Telephone 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
Required
Military Status
*
Active Duty
Reserve/National Guard
Veteran
How many years did you serve?
*
Your answer
What was your MOS or Specialty?
*
Your answer
How did you hear about this program?
*
Your answer
What is your reason for contacting us? (Retreat, Individual Therapy, Groups, etc?)
*
Your answer
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
Clear selection
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
Other:
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
Have you ever tested positive 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
Prefer not to answer
Other:
Clear selection
What is your Emergency Contact Number?
*
Your answer
Who is your Emergency Contact Person?
*
Your answer
What relation is this person to you?
*
Your answer
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
Thank you for your application. A member of our herd will contact you shortly.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Horse Sense of the Carolinas.
Report Abuse
Forms
