Home » Equine Assisted Therapy for At-Risk Youth Participant Application Equine Assisted Therapy for At-Risk Youth Participant Application Please complete this form as honestly and completely as possible. All information you provide will be confidential as required by State and Federal Law. Are you filling out this application for yourself or someone else? Myself For Someone else Name of Person filling out this Application(required) Date of Birth of Person filling out this Application (YYYY-MM-DD) Name of Youth Applicant (required) Date of Birth of Youth Applicant (YYYY-MM-DD) If filling this Application out for someone else, what is your relationship to the applicant? Parent or Legal Guardian Foster Parent Social Worker Friend Family Member I am filling out this application for myself Email(required) Phone Street Address City State Minnesota Wisconsin Other County Washington St. Croix Pierce Chisago Isanti Anoka Ramsey Hennepin Sherburne Wright Carver Scott Dakota Polk Dunn Pepin Other How did you hear about us? Select one option Search Engine Social Media Friend or Family Current or Former Windfall Equine Therapy Center Participant Newspaper Article Does the applicant have any prior experience with horses? If yes, please tell us more. Please share with us what you hope to gain from this experience. MENTAL HEALTH CHALLENGES In your own words, please share with us the current mental health challenges the applicant faces. How long has the applicant been experiencing mental health challenges? Only in the last year 2-4 years 5 years or more In the past, what has the applicant done to cope with mental health challenges? Was it helpful? What types of symptoms has the applicant experienced in the last 30 days? Difficulty falling asleep Difficulty getting out of bed to begin the day Loss of interest in previously enjoyed activities Withdrawing from friends and family Depressed mood Rapid mood changes Anxiety Feelings of Guilt Fear of certain objects or situations Outbursts of anger Spending increased time alone Feeling numb Irritability Panic attacks Feelings of worthlessness or hopelessness Feeling or acting like a different person Changes in eating, appetite, weight gain or loss Voluntary vomiting Self harm or self-mutilation/cutting Thoughts about harming someone else Suicidal ideation Intrusive memories or flashbacks Racing thoughts Difficulty thinking or concentrating Inability to decipher what is real and not real Unusual visual experiences such as flashes of light, shadows or hallucinations Concerns about sexuality or sexual orientation Difficulty problem solving Sense of being out of control Has the applicant seen a counselor, psychologist, psychiatrist or any other mental health professional before? Yes No If you answered yes, please provide the name of the therapist(s), the reason(s) for seeking help, and the approximate date(s) of treatment. Is the applicant CURRENTLY taking any PSYCHIATRIC medication? Yes No If you answered yes, please provide the name of the medication(s), dosage, duration the applicant has been using the medication, and if the medication is helpful. Has the applicant taken any PSYCHIATRIC medication in the past? Yes No If you answered yes, please provide the name of the medication(s), dosage, duration the applicant had been using the medication, and if the medication was helpful. Has the applicant been hospitalized for psychiatric reasons? Yes No If you answered yes, please provide the reason and the approximate date(s) of hospitalization. Has the applicant ever attempted suicide? Yes No If you answered yes, please tell us more about that. Please include approximate number of attempts along with approximate dates and circumstances surrounding them. Is the applicant CURRENTLY under treatment for any medical condition? Yes No If you answered yes, please tell us more about that. FAMILY HISTORY FATHER Is the applicant's father living or deceased? Living Deceased Not sure Age of father (if living) Cause of death of father (if deceased) How would you describe the applicant's relationship with his/her father? Check all that apply. Positive It has its ups and downs Difficult Emotionally abusive Physically abusive Sexually abusive Neglectful Non-existent MOTHER Is the applicant's mother living or deceased? Not sure Living Deceased Age of mother (if living) Cause of death of mother (if deceased) How would you describe the applicant's relationship with his/her mother? Check all that apply. Positive It has its ups and downs Difficult Emotionally abusive Physically abusive Sexually abusive Neglectful Non-existent SIBLINGS Please tell us about the applicant's siblings. How many sisters and brothers does the applicant have? How old are they? Please share with us about the applicant's relationships with siblings. Please tell us about the applicant's siblings. How many sisters and brothers does the applicant have? How old are they? What is the applicant's current living situation? Living with both parents Living with one parent Living with a legal guardian Living with a friend or relative Homeless Living in a foster home Living in a group home EDUCATION What is the applicant's highest grade level completed? Has the applicant been expelled from school? Yes No If yes, please explain. Does the applicant have a history of disciplinary problems in school? Yes No If yes, please explain. What kind of grades is/was the applicant most recently getting in school? Mostly A's Mostly B's Mostly C's Mostly D's Mostly F's A wide range of grades SOCIAL What kind of social activities does the applicant participate in? How often does the applicant participate in these activities? Has the applicant been arrested? Yes No If yes, please explain. SUBSTANCE ABUSE Does the applicant have a history of alcohol use? Yes No If yes, at what age did the applicant begin using alcohol? Does the applicant currently use alcohol? Yes No If yes, please describe the applicant's alcohol use in the last 30 days. Does the applicant have a history of drug use? Yes No If yes, at what age did the applicant begin using drugs? If the applicant has used multiple drugs, please list them all and the applicant's age when the applicant began using the drug. Does the applicant currently use drugs? Yes No If yes, please describe the applicant's alcohol use in the last 30 days. How do you prefer to be contacted by us? Email Text Message (standard data rates apply) Phone call (leave message if no answer) Which of the following upcoming sessions is the applicant interested in? Check all that apply. Fall 2024 Spring 2025 Summer 2025 Please indicate any areas the applicant may experience difficulty, have limitations, or may require assistance. loss of mobility or impaired movement hearing loss vision loss seizures spinal injuries balance and/or coordination pregnancy heart conditions (such as arrythmia, high blood pressure or heart disease) diabetes cognitive deficits (difficulty focusing or following instructions) Please share with us anything else you would like us to know about the applicant. Send Δ
