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Person Completing Form
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Are you someone other than the patient?
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Name of person completing this form
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Relationship to patient
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Patient Info
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How did you hear about TERRA?
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If referred by someone, who?
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Pronouns
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Relationship status (select all that apply)
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Others living in household (name, age, relationship)
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Religion
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Employment status (select all that apply)
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Most recent profession
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Current or most recent employer
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Student status
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Current or most recent school
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Current grade or highest level completed
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Did you, or did any member of your immediate family, serve in the military?
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Who in your family served in the military?
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In what branch(es)? (i.e., Army, Navy, Marines, Air Force, Coast Guard, or Space Force)
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Please do not check this box.
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Youth/Teen Additional Information
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Note: The contact information at the beginning of this form is used for scheduling, automated reminders, and patient contact.
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I acknowledge that the person whose contact information is listed at the beginning of this form has the permission and authority to manage scheduling, billing, and transportation to/from TERRA Equine Therapy Center.
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Youth/teen phone (or N/A)
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Youth/teen email (or N/A)
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Youth/teen's school
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Youth/teen's grade
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Any school grades repeated or skipped?
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More information on repeated/skipped grades
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Any expulsions, suspensions, or disciplinary issues?
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More information on expulsions, suspensions, or disciplinary issues
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Has the youth/teen ever had an IEP or 504 plan?
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What was the IEP or 504 plan for?
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Mother's name
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Mother's profession
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Mother's phone
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Mother's email
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Mother's address (if different from youth/teen)
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Father's name
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Father's profession
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Father's phone
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Father's email
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Father's address (if different from youth/teen)
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