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Client referral form/profileEquine/Animal Assisted Therapy & Learning
Service requested:(e.g. Siblings Together, AATL, AAOT etc.)Personal InformationName of referrer
Role/relationship in groupEmail/Phone Name of children/young peopleDOB and AgesName of Parents/ Carers/other adults in the family group referred
E-mail address(f different from above)Home phoneMobileAddress
GP Details
Please outline reason for referral along with any Emotional/Behavioural and/or Special Needs and health needs we may need to be aware of (section will expand on writing)
What does members of the group enjoy?(expand as necessary)What do they dislike?(expand as necessary)
Any known risks or anything at all you feel we should know about that you have not already mentioned?
Page | 1
(expand as necessary)
Date form completed
Page | 2
