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
Email*
example@example.com

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 – CONNECTICUT EQUINE LIABILITY ACT

Pursuant to Connecticut General Statutes § 52-557p, individuals engaged in equestrian activities assume the inherent risks and legal responsibility for any injury to their person or property arising from equestrian sports, except where such injury is proximately caused by:

The negligence of the person providing the horse; or
The failure to guard or warn against a dangerous condition, use, structure, or activity by the person providing the horse, or their agents or employees.

ACKNOWLEDGMENT OF RISK

I, on behalf of myself and/or my child/ward, acknowledge that equestrian sports involve inherent risks, including but not limited to the risk of serious physical injury, loss, and/or death. In accordance with Connecticut General Statutes § 52-557p, I fully assume all risks associated with equestrian activities, including but not limited to:

Variations in riding surfaces;
Man-made and natural obstacles;
Equipment failure;
Interactions with other riders, horses, and spectators; and
Any other conditions inherent to horseback riding.

I further acknowledge that while I assume these inherent risks, this release does not waive liability for gross negligence or willful misconduct by Ridgebury Farm and Stables, LLC and/or Ridgebury Riders, Inc. (hereinafter collectively referred to as “RF”), its trainers, instructors, guest instructors, officers, agents, volunteers, employees, or any individuals acting on its behalf.

I understand that this Agreement is intended to be as broad and inclusive as permitted by Connecticut law and that if any portion is held invalid, the remainder shall continue in full force and effect.

HORSES, PONIES & FARM ANIMALS:

I, on behalf of myself and/or my child/ward, acknowledge that while horses, ponies, and farm animals are domesticated, they remain unpredictable in nature. I understand that these animals may buck, shy, spook, kick, bite, trip, fall, or react unexpectedly to external stimuli, including but not limited to:

The actions of other horses, riders, or employees of RF;

Environmental factors such as noise, wind, changes in lighting; and

Unexpected natural or man-made obstacles beyond the control of RF.

I acknowledge that RF, its Trainers, Instructors, Barn Manager, Guest Instructors, Officers, Owners, Directors, Agents, Volunteers, and Employees cannot guarantee my safety while participating in equestrian activities.

INDEMNIFICATION:

I, on behalf of myself and/or my child/ward, for my heirs, assigns, successors, executors, administrators, and legal representatives, agree to indemnify and hold harmless RF, its guest or assistant instructors, Officers, Agents, Volunteers, and Employees from any and all lawful claims, suits, or demands arising from my participation in equestrian activities at RF, except in cases of gross negligence or willful misconduct by RF or its representatives.

RELEASE:

I acknowledge that equestrian activities involve inherent risks, and I assume full responsibility for any injury, loss, or damage that may occur while using the facilities, equipment, or animals owned or provided by RF. To the fullest extent permitted by law, I voluntarily waive any right to sue RF for injuries arising from the inherent risks of equestrian activities.

I, on behalf of myself and/or my minor child/ward, understand that RF may take photographs and/or videos of participants, riders, and volunteers during activities and events for promotional purposes in print, multimedia, or online formats (including social media).

If you or your child prefer not to be photographed or recorded, please notify the RF office in writing.

I understand that this Agreement is intended to be as broad and inclusive as permitted by Connecticut law, and if any portion is found to be unenforceable, the remainder shall continue in full force and effect.

By signing below, I affirm that:

I have read and fully understand this WARNING, INDEMNITY, HOLD HARMLESS, and RELEASE OF LIABILITY.

I understand that by signing this Agreement, I may be waiving certain legal rights.

I am signing this Agreement voluntarily and of my own free will.
Waiver*

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.
Medical Release*

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