Mental Health and Resilience Program Application

"*" indicates required fields

First Name (of Program Participant)*

Nickname or Preferred Name*

Last Name (of Program Participant)*

Pronouns*

Sex*

Ethnicity of Program Participant

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern/North African

Multiracial

Native Hawaiian or other Pacific Islander

White

Decline to state

Weight Range (We ask this in the event there is a riding component to the program).*

Up to 100 lbs.

101-150 lbs.

151-200 lbs.

201-250 lbs.

251-300 lbs.

Over 300 lbs.

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Phone*

Home Phone*

Applicant Email*

Applicant's Age*

Applicant's DOB*

Parent/Guardian section

If Program Participant is a minor or has a guardian, please fill in the following

Parent/Guardian #1 Name*

First Last

Parent/Guardian #1 Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian #1 Phone Number*

Parent/Guardian #1 Email*

Parent/Guardian #2 Name

First Last

Parent/Guardian #2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian #2 Phone

Parent/Guardian #2 Email

Hidden

Program of Interest*

Buckaroos (elementary school aged workshop)

Steps (middle school aged workshop)

Strides (high school aged workshop)

Trailblazers (middle school aged summer camp)

Healing with the Herd (cancer or other chronic illness workshop)

Veteran and First Responder Programs

Pathways (young adults 18-25)

Individual Walk and Talk services

Other

Military Branch of Service, or First Responder Field of Service

Breifly describe the services you are looking for*

Are you currently working or attending school? If so, where?*

Employement Status*

Employed, Full-time

Employed, Part-time

Employed, on Medical Leave

Not Employed

Other

Type of cancer or other chronic illness diagnosis*

Briefly describe your course of treatment*

Any other medical diagnosis*

Areas of your life that feel particularly challenging. Check all that apply.*

Are you currently in counseling/therapy?*

Yes

List any known mental health diagnoses*

List any known medical diagnoses*

Briefly describe your physical ability/fitness level*

Do you require special accommodations? If so, please describe*

Do you have previous horse experience? If so, please describe*

Describe your comfort level around horses*

What do you hope to gain from participating in a Mental Health and Resilience Program at NCEFT?*

Is there anything else we did not ask that you feel would be useful for us to know about you?

How did you heare about NCEFT? Check all that apply.*

Am a current or former NCEFT client

Referral from friend

Referral from medical professional

NCEFT website

NCEFT email or newsletter

Facebook, Instagram, or other social media

Internet search

Other

Mental Health and Resilience Program Application

Mental Health and Resilience Program Application