For all new patients, please email Anita on anita@equinereflections.com.au or text her on 0499 191 978.

Office hours 9am – 6pm. We may not be available at all times due to the nature of our work. If you require emergency support please click here.

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Name of Patient or (Parent/Carer if completing this form for a dependant) *

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Last

Correspondence will be directed to this person.

Patient or Parent/Carer's email *

Correspondence will be sent to this email address.

Patient or Parent/Carer's phone number *

This will be used for initial conversations and to then schedule appointments.

Name of Patient *

First

Last

Date of Birth of Patient

Would you like to book a School Holiday Program?

• Yes, for ages 5 – 12 years
• Yes, for ages 12 – 18 years
• No thank you, I’m enquiring about ongoing therapy sessions.

Anita will call to discuss your preferred date and time after receiving this form.

What are the main reasons for your enquiry today?

Do you have any mental or physical health concerns that you are keen to seek support with?

Eg: Emotional regulation, Anxiety, Stress, Concentration, ASD, ADHD, OCD, PTSD, LGBTIQA+ etc

What would you/your child like support with during your equine therapy sessions?

Are you currently working with any other therapists?

OT, Speech Pathologist, Psychologist, Psychiatrist etc

Any medications?

This question helps us to understand how you are currently being supported.

Have you experienced equine therapy before?

• Yes
• No

What horse experience do you have?

• None
• I’m nervous around horses
• I like animals but not sure about horses
• I’m very confident with horses

Are you an NDIS participant?

• Yes, Self Managed
• Yes, Plan Managed
• No, Private Client

How did you hear about us?

Any message?

Do you have any questions or like to share anything else with us?

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