Form

Equine Assisted Psychotherapy (EAP) General Interest Form

First Name

Last Name

Age

Gender

Email*

Phone Number

Is it okay to leave a voicemail?

Yes

No

Veteran or First Responder?

Veteran

First Responder

What branch did you serve in? Or, what kind of first responder were/are you?

Have you been deployed? If so, how many times?

When did you transition out of the military or leave work as a first responder?

I am interested in...

Individual Equine Assisted Psychotherapy (EAP)

Group EAP

Equine Assisted Learning (EAL) - Form Up Fridays

How did you hear about EAP/EAL at the BRBR?

What time of day do you prefer? If either time works best, please check both boxes.

A.M.

P.M.

What is your main goal in seeking these services?

Do you meet the definition of a disabled veteran or active duty Service Member with a disability? (Does not have to be service connected and you do not have to be enrolled in the VA).

Have you attended Warrior PATHH?

Are you currently in therapy?

Yes

No

If so, please list the name of your therapist.

Are you willing to allow Stephanie Czeresko, EAP Mental Health Specialist, to coordinate care with your provider?

Yes

No