Ridgebury Therapeutic Services Intake Form

Ridgebury Therapeutic Services Intake Form
Directions: Please fill out this form as it pertains to you or your child. Indicate sections as not applicable (N/A) if the requested information does not pertain to you or your child.
Are you filling this form for yourself or a dependent? If you are under 18 years of age, please select Dependent.*

MyselfDependent

Client Information
Client name*

First NameLast Name
Client date of birth*

MonthDayYear
Date
Client height (ft)*
Client height (in)*
Client weight (lbs)*

Contact Information
Phone number*
Please enter a valid phone number.
Email*

Address
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Education
School*
Grade*

Medical History
Allergies - please list any food or environmental allergies*
Does the client have an anaphylactic response to any of the listed allergens?*

YesNo
Medical information - current diagnoses, conditions, or medications*
Pertinent medical history - past surgeries, hospital stays, medications, or family medical history*

Medical Contacts
Insurance Information

Ridgebury Farm is out of network for all insurance providers. We can provide you with paperwork to submit to your insurance for reimbursement.
Do you plan to submit to insurance?*

YesNo
If yes, who is the provider?*
Emergency Contact
Name*
Phone Number*
Relationship to client*

Current Therapy
Therapy services currently receiving - select all that apply or none*

Occupational TherapyPhysical TherapySpeech TherapyABA TherapyVision TherapyNoneOther

Past Therapy
Past therapy services received - select all that apply or none*

Occupational therapyPhysical therapySpeech therapyABA therapyVision therapyNoneOther

Tell us more!
Client goals you are hoping to address:*
Client areas of skill and interest:*
Client areas of concern and difficulty:*

Ridgebury Farm and Stables, LLC.

WARNING, INDEMNITY, HOLD HARMLESS & RELEASE OF LIABILITY

WARNING:

Pursuant to Connecticut General Statures §52-557p, a person engaged in recreational activities assumes the risk and responsibility for any injury to his or her person or property arising out of the hazards inherent in equestrian sports, unless the injury was proximately caused by the negligence of the person providing the horse/pony or horses/ponies to the individual engaged in the equestrian activities, or the failure to guard or warn against a dangerous condition, use, structure or activity of the person providing the horse/pony and/or horses/ponies, or his or her agents and or employees.; and

ACKNOWLEDGEMENT:

I, and/or on behalf of my child listed below, understand that there is an inherent risk in equestrian sports, including but not limited to the risk of serious physical injury, loss and/or death. I fully assume all risks associated with equestrian sports, even if due to the NEGLIGENCE of Ridgebury Farm and Stables, LLC. (hereinafter referred to as “RFS, LLC.”), Ridgebury Farm and Stables, LLC, and its trainers & instructor(s) or guest or assistant instructors invited or hired by RFS, LLC., its Officers, Agents, Volunteers, Servants and/or Employees, including but not limited to variations in the indoor and outdoor ring conditions; man made obstacles; collisions with object either inside or outside the riding rings including but not limited to jumps, hay bales, shrubbery, rocks, equipment, natural obstacles, employees, participants, or other patrons and spectators on the property; lack of safety devices, or inadequate safety devices; lack of warning or inadequate warning; lack of instruction or inadequate instruction.; and

HORSES & PONIES:

I, or on behalf of my child listed below, understand that horses and ponies, although tame, trained and boarded at RFS, LLC., are in fact a “wild” animal, and may buck, shy, spook, kick, bite, trip, fall and/or react unexpectedly to the actions of other horses or ponies, riders, employees of RFS, LLC., and environmental effects including but not limited to noise, wind, light/darkness, or any man-made or environmental anomaly beyond the control of RFS, LLC. &, its Trainers, Instructors, Barn Manager, Guest Instructors, Officers, Owners, Directors, Agents, Volunteers, Servants and or Employees.; and

INDEMNIFICATION:

I, or on behalf of my child listed below, for myself and for my heirs, assigns, successors, executors, administrators and legal representatives, agree that I will defend, indemnify and hold harmless, RFS, LLC. and/or guest or assistant instructors invited by RFS,LLC., its Officers, Agents, Volunteers, Servants and/or Employees, free from any and all claims, suits or demands by anyone arising from my use of the facility, equipment and/or horses/ponies owned by or boarded at RFS, LLC. &, or brought onto the property by RFS, LLC or other parties.; and

RELEASE:

I, or on behalf of my child listed below, for myself and for my heirs, assigns, successors, executors, administrators and legal representatives, hereby release and agree that I will not sue RFS, LLC., and its trainer/instructors/managers, or guest or assistant instructors invited by RFS, LLC., its Owners, Officers, Agents, Volunteers, Servants and/or Employees, for money damages and/or for any injury, loss and/or death, emotional distress, or from theft to person, horse/pony or possession, sustained by me while using the facility, equipment and/or horses/ponies owned by, boarded at RFS, LLC., or brought onto the property for use by RFS, LLC., even if due to the NEGLIGENCE of RFS, LLC., and its trainers/instructors/managers named above or guest or assistant instructors invited by RFS LLC., its Officers, Agents, Volunteers, Servants and/or Employees.; and
I verify that I have read and agree to the statement above

COVID-19 ACKNOWLEDGEMENT:

WHERAS, Client affirms the following statement for themselves and/or on behalf of their minor child:

I AM AWARE OF THE COVID-19 PANDEMIC AND RELATED STATE OF CONNECTICUT GOVERNMENTAL ORDERS, DIRECTIVES AND GUIDELINES (COLLECTIVELY “DIRECTIVES”), INCLUDING DIRECTIVES FOR FREQUENT HAND WASHING, SOCIAL DISTANCING AND USE OF FACE MASKS IN PUBLIC. I AM AWARE THAT I COULD BE INFECTED, SERIOUSLY INJURED OR EVEN DIE DUE TO COVID-19, OR DUE TO CHOOSING TO PARTICIPATE IN RIDING ACTIVITIES AT RFS, LLC. I AM VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES WITH KNOWLEDGE OF THE DANGER INVOLVED AND AGREE TO ASSUME ANY AND ALL RISKS OF BODILY INJURY, DEATH OR PROPERTY DAMAGE, WHETHER THOSE RISKS ARE KNOWN OR UNKNOWN INLIGHT OF THE GLOBAL COVID-19 PANDEMIC.
I verify that I have read and agree to the statement above

Emergency Medical Release

In the event of a medical emergency, I give permission for Ridgebury Farm staff to call emergency medical services.
I verify that I have read and agree to the statement above

PHOTOGRAPHY/ VIDEO:

I, or on behalf of my minor child listed below, understand that RFS LLC may take photos and/or videos of program participants, riders, and volunteers, during activites and events conducted at RFS LLC, for use in promotional materials in prints, multimedia, and web form (including social media outlets). Photos and/or videos will only be used for the purposes related to RFS and its programs.
Please verify by checking the box:*

I consent to having photos and/or videos taken of me and/or my dependentI consent to having photos and/or videos taken of me and/or my dependent for medical records only (not used for any public media)I do not consent to having photos and/or videos taken of me and/or my dependent

SIGNATURE:

I have read the WARNING, INDEMNITITY, HOLD HARMLESS and RELEASE OF LIABILITY, COVID-19 ACKNOWLEDGEMENT, and EMERGENCY MEDICAL RELEASE, and fully understand their terms. I further understand that by signing this agreement that I may be waiving specific legal rights, either for myself or for my undersigned child on whose behalf I am signing this agreement. I have not been induced to sign this agreement and have not signed same pursuant to any promise or representation which has not been attached hereto, if any. I sign said agreement voluntarily and of my own free will.
Signature*

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Ridgebury Therapeutic Services Intake Form
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Ridgebury Therapeutic Services Intake Form

Client Information

Contact Information

Address

Education

Client Information

Medical History

Medical Information

Medical Contacts

Insurance Information

Emergency Contact

Current Therapy

Past Therapy

Tell us more!

Client Background Information for Therapy Services

Emergency Medical Release