Youth Participant Application

Are you filling out this application for yourself or someone else?

Myself

For Someone Else

Name of Person filling out this Application

Date of Birth of Person filling out this Application (MM/DD/YYYY)

Name of Youth Applicant

Date of Birth of Youth Applicant (MM/DD/YYYY)

If filling this Application out for someone else, what is your relationship to the applicant?

Parent or Legal Guardian

Foster Parent

Social Worker

Friend

Family Member

I am filling out this application for myself

Email

Phone

Street Address (Include City, State and Zip Code)

County

Washington

St. Croix

Pierce

Chisago

Isanti

Anoka

Ramsey

Hennepin

Sherburne

Wright

Carver

Scott

Dakota

Polk

Dunn

Pepin

Other

How did you hear about us?

Does the youth applicant have any prior experience with horses? If yes, please tell us more.

Please share with us what the goals from this experience for the youth applicant.

How long has the applicant been experiencing mental health challenges?

Less than one year

Between 2 and 4 years

5 years or more

No known mental health challenges

In the past, what has been done to cope with mental health challenges? Was it helpful?

What types of symptoms has the applicant experienced in the last 30 days?

Difficulty falling asleep

Difficulty getting out of bed to begin the day

Loss of interest in previously enjoyed activities

Withdrawing from friends and family

Depressed mood

Rapid mood changes

Anxiety

Feelings of Guilt

Fear of certain objects or situations

Outbursts of anger

Spending increased time alone

Feeling numb

Irritability

Panic attacks

Feelings of worthlessness or hopelessness

Feeling or acting like a different person

Changes in eating, appetite, weight gain or loss

Voluntary vomiting

Self harm or self-mutilation/cutting

Thoughts about harming someone else

Suicidal ideation

Intrusive memories or flashbacks

Racing thoughts

Difficulty thinking or concentrating

Inability to decipher what is real and not real

Unusual visual experiences such as flashes of light, shadows or hallucinations

Concerns about sexuality or sexual orientation

Difficulty problem solving

Sense of being out of control

None of the above

Has the applicant seen a counselor, psychologist, psychiatrist or any other mental health professional before?

Yes

No

If you answered yes, please provide the name of the therapist(s), the reason(s) for seeking help, and the approximate date(s) of treatment.

Is the applicant CURRENTLY taking any PSYCHIATRIC medication?

Yes

No

If you answered yes, please provide the name of the medication(s), dosage, duration the applicant has been using the medication, and if the medication is helpful.

Has the applicant taken any PSYCHIATRIC medication in the past?

Yes

No

If you answered yes, please provide the name of the medication(s), dosage, duration the applicant had been using the medication, and if the medication was helpful.

Has the applicant been hospitalized for psychiatric reasons?

Yes

No

If you answered yes, please provide the reason and the approximate date(s) of hospitalization.

Has the applicant ever attempted suicide?

Yes

No

If you answered yes, please tell us more about that. Please include approximate number of attempts along with approximate dates and circumstances surrounding them.

Is the applicant CURRENTLY under treatment for any medical condition?

Yes

No

If you answered yes, please tell us more about that.

Is the applicant's father living or deceased?

Living

Deceased

Not sure

Age of father (if living, or at time of death)

Cause of death of father (if deceased)

How would you describe the applicant's relationship with their father? Check all that apply.

Positive

It has its ups and downs

Difficult

Emotionally abusive

Physically abusive

Sexually abusive

Neglectful

Non-existent

Is the applicant's mother living or deceased?

Not sure

Living

Deceased

Age of mother (if living, or at time of death)

Cause of death of mother (if deceased)

How would you describe the applicant's relationship with his/her mother? Check all that apply.

Positive

It has its ups and downs

Difficult

Emotionally abusive

Physically abusive

Sexually abusive

Neglectful

Non-existent

Please tell us about the applicant’s siblings. How many sisters and brothers does the applicant have? How old are they?

Please share with us about the applicant’s relationships with siblings.

What is the applicant's current living situation?

Living with both parents

Living with one parent

Living with a legal guardian

Living with a friend or relative

Homeless

Living in a foster home

Living in a group home

What is the applicant’s highest grade level completed?

Has the applicant ever been expelled from school?

Yes

No

If yes, please explain.

Does the applicant have a history of disciplinary problems in school?

Yes

No

If yes, please explain.

What kind of grades is/was the applicant most recently getting in school?

Mostly A's

Mostly B's

Mostly C's

Mostly D's

Mostly F's

A wide range of grades

What kind of social activities does the applicant participate in? How often does the applicant participate in these activities?

Has the applicant been arrested?

Yes

No

If yes, please explain.

Does the applicant have a history of alcohol use?

Yes

No

If yes, at what age did the applicant begin using alcohol?

Does the applicant currently use alcohol?

Yes

No

If yes, please describe the applicant’s alcohol use in the last 30 days.

Does the applicant have a history of drug use?

Yes

No

If yes, at what age did the applicant begin using drugs? If the applicant has used multiple drugs, please list them all and the applicant’s age when the applicant began using the drug.

Which of the following sessions is the applicant interested in?

4 weeks in July (Day/Time/TBD)

4 weeks in August (Day/Time/TBD)

4 weeks in September (Day/Time/TBD)

Please indicate any areas the applicant may experience difficulty, have limitations, or may require assistance.

loss of mobility or impaired movement

hearing loss

vision loss

seizures

spinal injuries

balance and/or coordination

pregnancy

heart conditions (such as arrythmia, high blood pressure or heart disease)

diabetes

cognitive deficits (difficulty focusing or following instructions)

Please share with us anything else you would like us to know about the applicant.

Youth Participant Application

Are you filling out this application for yourself or someone else?

If filling this Application out for someone else, what is your relationship to the applicant?

County

Mental Health Questionnaire

How long has the applicant been experiencing mental health challenges?

What types of symptoms has the applicant experienced in the last 30 days?

Has the applicant seen a counselor, psychologist, psychiatrist or any other mental health professional before?

Is the applicant CURRENTLY taking any PSYCHIATRIC medication?

Has the applicant taken any PSYCHIATRIC medication in the past?

Has the applicant been hospitalized for psychiatric reasons?

Has the applicant ever attempted suicide?

Is the applicant CURRENTLY under treatment for any medical condition?

Family History

Is the applicant's father living or deceased?

How would you describe the applicant's relationship with their father? Check all that apply.

Is the applicant's mother living or deceased?

How would you describe the applicant's relationship with his/her mother? Check all that apply.

What is the applicant's current living situation?

Education Questionnaire

Has the applicant ever been expelled from school?

Does the applicant have a history of disciplinary problems in school?

What kind of grades is/was the applicant most recently getting in school?

Social Questionnaire

Has the applicant been arrested?

Substance Abuse Questionnaire

Does the applicant have a history of alcohol use?

Does the applicant currently use alcohol?

Does the applicant have a history of drug use?

Wrap Up

Which of the following sessions is the applicant interested in?

Please indicate any areas the applicant may experience difficulty, have limitations, or may require assistance.