Client Information Form

Please submit the following, or if you prefer, download the .pdf form, print and mail to:
Northland Therapeutic Riding Center
P.O. Box 1267
Kearney, MO 64060

MENTAL HEALTH DATA
(Please complete if applicable.)

Client's Name:

Age: DOB: Sex: Male Female Height: Weight:

Parent/Guardian name (If under 18 years):

Parent/Guardian Phone:
Home Phone: Work Phone:

Home Address:

City: State: Zip:

Physician's Name:

Physician's Phone:

Therapist's Name:

Therapist's Phone:

Diagnosis (DSM-IV)

Axis I
Axis II
Axis III
Axis IV
Axis V

Presenting Problems:


Current medications:

Drug
Dose
Route
Time
Purpose

Psychiatric Treatment History:

Where
When
Diagnosis
Current Therapy
Outpatient Therapy
Inpatient Therapy

Therapeutic and Safety Issues



Check and describe applicable issues (indicate current or history of):

Inattention
Hyperactivity
Lack of concentration
Learning disabilities
Developmentally delayed
Mentally challenged
Boundary issues
Social skills problems
Problem with peers
Separation anxiety
Anxiety
Phobias
Aggressive
Assaultive
Manipulative
Unpredictable or
dangerous behavior
Sensory impairment
Sensitivity, preferences
Tics or stereotypic behavior
Psychosomatic symptoms
Medical issues
Self-injurious behavior
Suicidal ideations
History of runaway
Issues of parental support
Issues of family support
Sexual abuse/acting out
History of physical
Emotional abuse
Hallucinations
Delusions
Illusions
Dissociations
Substance abuse
problems
Legal problems
School problems
History of animal abuse
and/or fire setting
Seizure disorder
Possible medication
side effects


Information Source:

Date Form Completed:



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