Home » Equine Assisted Therapy for Veterans Participant Application Equine Assisted Therapy for Veterans 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 a veteran of the US Armed Forces? Yes No Under which branch of the US Armed Forces did you serve? Army Navy Air Force Marines Coast Guard Army National Guard Air National Guard Space Force Which form of veteran ID can you provide to verify your veteran status? DD-214 Form DoD ID Card Veteran ID Card (VIC) Name(required) 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 Date of Birth (YYYY-MM-DD) 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 Do you have any prior experience with horses? If yes, please tell us more. Please share with us what you hope to gain from this experience. 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 are you interested in? Check all that apply. Fall 2024 Spring 2025 Summer 2025 Please indicate any areas you may experience difficulty, have limitations, or may require assistance. hearing loss vision loss loss of mobility or impaired movement 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 a little about yourself. MENTAL HEALTH CHALLENGES In your own words, please share with us the current mental health challenges you are facing. How long have you been experiencing these mental health challenges? Only in the last year 2-4 years 5 years or more In the past, what have you done to cope with or improve your mental health challenges? Was it helpful? What types of symptoms have you 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 What kinds of stress factors have you experienced in the last 2 years? Loss of job(s) Loss of important relationship(s) Death of close friend(s) or family member(s) Significant illness or injury of close friend(s) or family member(s) Significant financial loss or debt Losing a home Moving to a new community Victim of domestic violence Witness to traumatic event(s) Significant illness or injury Partial loss of mobility, strength or function due to illness or injury Child custody dispute(s) Legal/court/criminal dispute(s) Have you 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. Are you CURRENTLY taking any PSYCHIATRIC medication? Yes No If you answered yes, please provide the name of the medication(s), dosage, duration you have been using the medication, and if the medication is helpful. Have you taken any PSYCHIATRIC medication in the past? Yes No If you answered yes, please provide the name of the medication(s), dosage, duration you have been using the medication, and if the medication was helpful. Have you ever been hospitalized for psychiatric reasons? Yes No If you answered yes, please provide the reason and the approximate date(s) of hospitalization. Have you 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. Are you CURRENTLY under treatment for any medical condition? Yes No If you answered yes, please tell us more about that. SOCIAL What kind of social activities do you participate in? How often do you participate in these activities? Have you been arrested? Yes No If yes, please explain. SUBSTANCE ABUSE Do you have a history of alcohol abuse? Yes No If yes, how long ago or at what age did you begin abusing alcohol? About how many drinks do you usually have per week? Less than 3 4-10 More than 10 How much does drinking alcohol negatively effect your relationships with friends and family? Not at all Sometimes Most of the time All the time How much does drinking alcohol interfere with your responsibilities at home or at work? Not at all Sometimes Most of the time All the time If you start drinking, do you find it difficult or impossible to stop? Not at all Sometimes Most of the time All the time Do you have a history of drug use? Yes No What types of drugs (not including drugs that were prescribed to you) are you using currently or have used in the past? Click all that apply. Cannabis/Marijuana'Cannabis/Marijuana Depressants Cocaine or crack Fentanyl Heroin Inhalants Ketamine LSD or acid MDMA/ecstasy Mescaline/peyote Methamphetamine Opioids/Oxy/Percs PCP/angel dust Speed Psilocybin/mushrooms Rohypnol/flunitrazopam/roofies Steroids (anabolic) Synthetic cathinones/bath salts/flakka If you checked any of the drugs listed above, please tell us more about your age when you started using each drug, and how long it has been since the last time you used the drug. If you are currently using drugs, please describe your drug use in the last 30 days. Please share with us anything else you would like us to know about you. Send Δ
