Equine Therapy Initial Evaluation (OT/PT/SLP)

Date of Service: [Date of service]

Patient Name: [Full name]

DOB: [Date of birth]

Discipline(s): [OT / PT / SLP] (Select one or more if co-evaluating)

Location: [clinic / barn / arena / community]

Therapist Name/Credentials: [Name, credentials]

Equine Professional/Handler: [Name / N/A] (Include only if equine involvement is being considered)

Referring Clinician: [Name / "Pending verification"]

Order Date: [Date / "Pending receipt of order"]

Diagnosis on Referral: [Referral diagnosis / "Pending review of referral"]

Consent Obtained: [yes / no], [patient / caregiver / legal guardian]; [interpreter used: language / N/A]

Equine Environment Consent Reviewed: [yes / no] (Include only if equine involvement is being considered)

(This is an OT/PT/SLP evaluation. When documenting equine components, use terminology: "equine movement (hippotherapy) as a treatment tool within OT/PT/SLP.")

Reason for Referral

[Referral reason, chief concern in patient/caregiver words, functional impact prompting evaluation] (1–3 sentences focusing on what the problem prevents the patient from doing.)

History

Information Sources: [patient report / caregiver report / chart review / other]

• Pertinent Medical History: [Primary diagnoses, comorbidities affecting therapy participation or risk, relevant surgical history, current precautions, current medications with risk-relevant effects, relevant allergies or sensitivities] (If equine involvement is being considered, note sensitivities relevant to equine environments such as animal dander, hay/dust, insect stings.)
• Prior Therapy Services and Response: [Disciplines, frequency/duration, key outcomes, reasons for discharge or changes]
• Social/Developmental Context: [Living situation, school/work demands, transportation constraints, relevant cultural or trauma-informed considerations] (Include only as it informs function and feasibility.)
• Prior Level of Function (PLOF): [Baseline functional abilities prior to onset/decline] (If unknown, state explicitly and note plan to clarify.)
• Current Function, Supports, and Safety: [Current assistance levels, devices/equipment used, safety needs, supervision requirements]
• Patient/Caregiver Goals: [2–5 participation-focused goals across home/school/work/community] (Frame as functional outcomes, not modality-specific desires.)

Equine Participation Screening

(Include this section only when equine involvement is being considered.)

• Prior Horse Exposure: [History of fear/avoidance, prior falls/incidents, prior successful participation]
• Sensory and Environment Tolerance: [Noise, smells, outdoor temperature, helmet tolerance, grooming/tactile tolerance]
• Behavioral/Self-Regulation: [Elopement risk, impulsivity, startle response, interactions with animals, ability to wait/transition]
• Patient-Reported Medical Risk Factors: [Seizure control status, syncope history, cardiopulmonary symptoms with exertion, severe allergies/asthma triggers, recent surgeries or wounds, orthopedic instability, indwelling devices] (Flag concerns for the Precautions section.)

Examination

General Observations: [Arousal, attention, affect, ability to follow commands, communication mode, posture, movement quality, endurance, pain assessment with scale used] (Include behavioral pain indicators if nonverbal.)

Vitals: [HR, BP, RR, O2 sat, position and timing] (Include only if indicated by diagnosis or risk profile.)

Tests and Measures: (For each test: name/version, context, scores with interpretation anchored to function. If standardized testing was not completed, document reason and alternative method used.)

• PT Measures: [Strength, ROM, tone, balance, gait, transfers, endurance] (Include only those performed; specify with/without device, surface type, assistance level.)
• OT Measures: [ADL performance, fine motor, visual-motor, sensory processing, participation routines] (Include only those performed.)
• SLP Measures: [Speech production, language, voice, fluency, AAC evaluation, feeding/swallowing with safety observations] (Include only those performed.)

Functional Performance Observations: [Mobility and transfers, fall risk behaviors, ADL performance, feeding/swallowing safety, classroom or work task performance, communication effectiveness] (Document assistance levels: [independent / supervision / minimal assist / moderate assist / maximal assist / dependent] and safety cues required.)

Equine Environment Screening

(Include this section only when equine involvement is being considered. Distinguish between findings observed today versus reported.)

• Physical Readiness for Mounted Work: [Head/trunk control, sitting tolerance, hip abduction tolerance, weight-bearing restrictions, skin integrity at contact points]
• Cognitive/Behavioral Readiness: [Ability to follow 1–2 step directions, safety awareness, startle response, impulse control]
• Communication Readiness: [Reliable yes/no response, ability to indicate pain/fear/stop, AAC accessibility plan for barn environment]
• Fall and Injury Risk Factors: [Balance reactions, spasticity/dystonia severity, uncontrolled movements, seizure risk, anticoagulation status, osteoporosis risk]
• Equipment Feasibility: [Helmet fit and tolerance, appropriate footwear, orthoses, positioning needs]
• Staffing Needs Estimate: [Equine handler required, number of side-walkers, mounting method, emergency dismount feasibility] (This is an estimate, not a commitment.)
• Equine Exposure This Visit: [direct trial completed / screening only] (If screening only, specify what requires direct trial.)

Precautions and Contraindications

General Therapy Precautions

• [General therapy precautions relevant to OT/PT/SLP participation]

Equine Movement (Hippotherapy) Precautions and Contraindications

(Include this subsection only when equine involvement is being considered.)

• Absolute Contraindications: [List if present: uncontrolled seizures, unstable spine/joints, open wounds over weight-bearing surfaces, active unsafe mental health conditions, other] (If any are present, explicitly state: "Equine movement contraindicated" and document the alternative plan.)
• Precautions (Relative Contraindications): [Each precaution with why it increases risk, planned mitigations, monitoring/stop criteria] (Do not imply medical clearance unless documented; if needed, state "clearance requested/pending.")

Assessment

[Synthesis connecting key impairments to activity limitations to participation restrictions; baseline levels for primary functional targets]

Problem List: [Problems in priority order: safety/medical severity first, then function and participation] (Each problem should be observable and measurable.)

Clinical Reasoning Regarding Equine Movement: (Include only when equine involvement is recommended or being considered.) [Targeted functional outcomes equine movement is expected to support; patient-specific risks and planned mitigations; shared decision-making participants] (If equine movement is not selected, document rationale and alternative skilled approach.)

Skilled Need: [Why OT/PT/SLP services are required and cannot be safely/effectively performed by unskilled personnel]

Prognosis: [good / fair / guarded] with [supporting factors and barriers to progress]

Goals

Long-Term Goals

• [SMART goal: functional target behavior, conditions, measurement criterion, timeframe, baseline from this evaluation]
• [SMART goal]

(Frame any equine-related goals as functional outcomes, not activity tolerance.)

Short-Term Goals

• [SMART goal]
• [SMART goal]
• [SMART goal]

Plan of Care

• Diagnoses Addressed: [Therapy diagnosis and relevant medical diagnoses]
• Planned Interventions: [Therapeutic activities, neuromuscular re-education, ADL training, sensory regulation strategies, AAC intervention, swallowing therapy, caregiver training, other] (Include plain-language purpose for each.)
• Integration of Equine Movement: (Include only when equine involvement is planned.) [How equine movement will be used as one tool among others; setting plan if known; minimum safety requirements; criteria to hold or modify equine component]
• Frequency and Duration: [Visits per week, minutes per session, episode length in weeks] (If not finalized, document provisional range with specific contingency.)
• Re-evaluation Plan: [Timeframe and standardized measures to be repeated]

Education and Coordination

• Education Provided: [Topics: safety, home program, communication strategies, positioning, other; method; understanding confirmed]
• Equine-Specific Education: [Helmet use, appropriate clothing and footwear, allergy management plan, arrival routines] (Include only if equine involvement is planned.)
• Coordination: [Referrals placed, medical clearance requests, communication with school/physician/equine professional]

Therapist Signature: [Signature]

Credentials: [Credentials]

Date/Time Signed: [Date and time]

(When equine involvement is not being considered or is deferred, omit the equine-specific sections and document rationale in the Assessment and/or Plan of Care.)