Date________________

 RIDER'S NAME: ____________________________________________________Age:__________

 
 Rider, Parent, Guardian:

Therapeutic riding provides participants an opportunity to enhance their well being in many ways.
Several areas are listed below which indicate the potential benefits. Please indicate and describe the
specific areas of learning you or your child are interested in working on during this riding session. A
member of our staff will discuss these with you.


Previous or current speech, occupational, and physical therapy______________________________________

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Names of therapists________________________________________________________________________

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COGNITION/PERCEPTION (-attention, following directions, memory, processing sensations such as vision, touch, hearing, movement) _______________________________________________________________________

_________________________________________________________________________________________

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PHYSICAL (posture, balance, strength, coordination, muscle tone) _____________________________________

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EDUCATIONAL (learning riding skills, and about horses; grooming, tack) ________________________________

__________________________________________________________________________________________

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RECREATIONAL (fun, socialization, self esteem) ___________________________________________________

__________________________________________________________________________________________

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COMMUNICATION (skills such as understanding others and expressing oneself) ___________________________

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