Equine-Assisted Psychotherapy Intake Assessment

Client Name: [Client name]

DOB: [Date of birth]

Date of Service: [Date]

Service Type: Equine-Assisted Psychotherapy Intake Assessment

Setting: [on-site equine facility / clinic / telehealth for intake]

Start Time / Stop Time / Total Time: [Start time] / [Stop time] / [Total time]

Mental Health Clinician: [Name, credentials]

Equine Specialist: [Name, credentials/role]

Other Individuals Present: [Caregiver / interpreter / observer / none]

Information Sources: [client report / caregiver / referral records / prior chart / other]

[Atypical circumstances context statement] (Only include if atypical circumstances occurred such as crisis, client intoxication, weather disruption, or incomplete visit. Keep to 1–2 sentences.)

Reason for Visit

[Reason for seeking care now, referral source, and client's stated goals including interest or uncertainty about equine-assisted work] (Begin with a direct statement of why the client is presenting now. Use a direct quote when it clarifies severity or impairment. If reason not obtained, state why and plan to obtain.)

Informed Consent and Equine Orientation

• Consent for behavioral health services and limits of confidentiality: [agreed / declined / deferred] — [Details of what was reviewed]
• Team-based care model explanation: [agreed / declined / deferred] — [Details of equine specialist involvement and information sharing per program policy]
• Equine modality orientation: [agreed / declined / deferred] — [Details of ground-based vs mounted work, session structure, safety briefing, participation requirements]
• Physical and environmental risks acknowledged: [acknowledged / declined / deferred] — [Inherent risks of large animals, uneven terrain, weather exposure, allergens]

[Explanation if consent could not be obtained and statement that encounter was limited to crisis evaluation/supportive intervention] (Only include if consent was not obtained.)

Presenting Concerns and History

[Chief concern in client's words] [Chronological history including onset, duration, course, precipitating factors] [Relevant symptom domains assessed: mood, anxiety, trauma symptoms, sleep, appetite, concentration, psychosis-spectrum] [Current severity and functional impact on relationships, school/work, and self-care] [Prior coping strategies and responses] [Client strengths and protective factors] [Prior experience with horses/animals and emotional response] (Do not infer symptom absence. If a domain was not assessed or client declined to answer, explicitly document "not assessed" or "client declined.")

Psychiatric and Treatment History

• Prior diagnoses: [Diagnoses with source and approximate dates]
• Prior therapy: [Type, frequency/duration, response, dates]
• Hospitalizations/higher levels of care: [Facility/level, dates, reason, outcome]
• Psychiatric medications: [Current medications with dose, frequency, adherence, response, side effects] [Past medications and responses]
• Self-harm and suicide history: [NSSI/attempts with timing, method, lethality, intent]
• Aggression/violence toward others: [History and context]
• Records status: [Records reviewed / pending and what has been requested]

Substance Use History

• Alcohol: [Frequency, quantity, last use, risks]
• Cannabis: [Frequency, quantity, last use, risks]
• Opioids: [Frequency, quantity, route, last use, risks]
• Stimulants: [Frequency, quantity, route, last use, risks]
• Sedatives: [Frequency, quantity, last use, risks]
• Nicotine: [Frequency, route, last use]
• Other substances: [Substance, frequency, quantity, route, last use, risks]
• Prior SUD treatment and recovery supports: [Details]

Intoxication/withdrawal considerations: [Assessment of current intoxication or withdrawal risk and impact on equine session eligibility] (Required if intoxication suspected or reported. Document how this affects eligibility and the immediate plan.)

Medical History (Equine-Relevant)

• Cardiopulmonary conditions: [Details and equine-setting implications]
• Seizure/syncope history: [Details and equine-setting implications]
• Mobility/neuromuscular limitations or fall risk: [Details and implications for uneven terrain]
• Medications affecting sedation/balance: [Agents and equine-setting implications]
• Allergies/asthma/reactive airway: [Details and equine-setting plan]
• Sensory limitations: [Vision/hearing details and impact on safety instruction comprehension]
• Recent injuries or chronic pain: [Location, severity, impact on movement]
• Primary Care Provider: [Name, contact]
• Emergency Contact: [Name, relationship, phone]

Equine-setting implications summary: [Brief synthesis of how medical findings affect participation and safety adaptations needed]

Developmental and Educational History

(Include this section for minors, young adults with developmental concerns, or when cognitive limitations affect consent or safety participation.)

• Developmental milestones/neurodevelopmental diagnoses: [Details]
• School functioning: [IEP/504 status, attendance, performance, supports]
• Guardian/custody and consent authority: [Details]

Trauma and Safety History

[Trauma exposure categories] [Current safety concerns] [Client's tolerance for trauma disclosure and pacing considerations] [Mandated reporting triggers and actions taken if applicable] (Document trauma exposure without requiring graphic details. Note domestic violence, unsafe home environment, or exploitation concerns.)

Social and Contextual Factors

• Living situation and key relationships: [Details]
• Work/school/vocational status: [Details]
• Legal involvement: [Probation, court orders, or none]
• Cultural/spiritual factors affecting care: [Preferences and considerations]
• Supports and stressors: [Current supports and major stressors]
• Practical considerations for equine sessions: [Transportation, scheduling, accessibility needs]

Mental Status Examination

• Appearance: [Description]
• Behavior/psychomotor: [Description]
• Speech: [Rate, volume, tone]
• Mood: "[Client's words]"
• Affect: [Range, reactivity, appropriateness]
• Thought process: [Coherence, linearity, goal-directedness]
• Thought content: [Delusions, obsessions, preoccupations, SI/HI]
• Perceptions: [Hallucinations, illusions, or none reported]
• Cognition and orientation: [Orientation, recall, abstract thinking]
• Attention/concentration: [Description]
• Insight and judgment: [Description]
• Impulse control: [Description]
• Engagement and reliability as historian: [Description]
• Equine-specific behavioral observation: [Observations of instruction-following, boundary respect, anxiety level near horses, other safety-relevant behaviors] (Include if on-site orientation with horses occurred.)

Risk Assessment

Suicide Risk: [Current ideation, plan, intent, access to means, preparatory behaviors; past attempts and self-injury; protective factors and reasons for living]

Violence Risk: [Ideation toward others, plan/intent, identified targets, access to weapons; history of violence or impulsivity]

Other Safety Concerns: [Self-care/grave disability concerns; abuse/neglect concerns]

Risk Formulation: [Narrative synthesis of risk drivers and protective factors] (Do not rely solely on categorical labels.)

Interventions: [Actions taken: safety plan status, crisis resources provided, lethal means counseling, disposition decision, notifications made]

[Explanation if any risk domain was not assessed, including why, immediate safety steps taken, and plan to assess] (Include only if risk assessment was incomplete.)

Equine-Assisted Appropriateness Screening

Eligibility Summary: [Synthesis of clinical indications supporting equine-assisted approach, client's willingness and capacity to engage safely, and any immediate exclusions or required modifications]

Contraindications and Precautions Review: (Document [present / absent / not assessed] for each domain with plan if concern is identified.)

• Animal-related: [Severe allergy/asthma unmanageable in setting; significant fear/phobia or traumatic history with horses; strong aversion to animals impairing engagement]
• Behavioral safety: [Unpredictable agitation/severe impulsivity; inability to follow directions; active intoxication/withdrawal; recent violence/credible threats; animal-directed aggression history or concern; severe dissociation/psychosis/mania impairing reality testing; elopement risk/boundary violations]
• Medical/physical: [Seizure/syncope risk; significant fall risk/mobility limitation on uneven terrain; sedating medications; heat/cold intolerance; open wounds or immunocompromised status]

Safety Orientation: [Documentation that orientation was provided to horse approach boundaries, facility rules and restricted areas, and emergency procedures including stop signal, notification protocol, and evacuation location]

Accommodations: [Planned modifications: ground-only interactions / increased distance / individual vs group format / additional staff support / session duration limits / scheduling adjustments / PPE requirements / none required]

Diagnostic Impression and Formulation

Diagnoses:

• [Diagnosis] — [ICD/DSM code] — [confirmed / provisional] (If provisional, specify additional information needed.)
• [Diagnosis] — [ICD/DSM code] — [confirmed / provisional]
• [Differential considerations if relevant]

Formulation: [Biopsychosocial narrative explaining predisposing, precipitating, perpetuating, and protective factors; link to presenting concerns and risk findings; clinical rationale for equine-assisted approach] (Provide explicit supporting evidence for diagnoses. Rationale may include experiential engagement, nonverbal processing, relational pattern exploration, somatic awareness.)

Treatment Plan

• Client Goals: [Goals in client's own words]
• Clinical Goals: [Specific, measurable targets addressing symptoms and functioning]
• Proposed Treatment: [equine-assisted sessions / office-based / combined] — [Frequency] — [individual / group] — [Initial focus]
• Care Coordination: [Releases needed; collaboration with other providers; referrals]

Disposition and Follow-Up

• Disposition: [Outpatient appropriate / urgent evaluation recommended / higher level of care recommended] — [Brief rationale]
• Safety Plan: [completed today / deferred / not indicated] — [Location stored] — [Who received copy]
• Crisis Resources: [Resources provided to client]
• Follow-Up: [Next appointment date/time] — [Interim contact plan]

Signature and Credentials: [Clinician name, credentials]

Date/Time of Signature: [Date and time]