Individual Application — Miranda Carey - Equine Facilitated Psychotherapy

Application For Individuals

All personal information you provide to us will be respected as confidential and your content details kept privately at all times.

Name

First Name

Last Name

Phone

(###)

###

####

Occupation

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact and Telephone Number

When would you like to attend?

YYYY

Are you currently with a counsellor/psychotherapist?

Yes

If not, do you readily have access to a counsellor/psychotherapist?

Yes

Please describe any special dietary needs you may have:

Please describe any particular medical or physical needs you may have when working with and around the horses:

Briefly share your experience with horses (please note equine experience is not necessary for this work):

What would you like to learn/gain from this work?

How did you hear about the workshop?