Consent for Equine Assisted Psychological Services

Child's name *

DOB *

Gender *

Parent 1 Name *

Parent 2 Name

Parent 1 Mobile number *

Parent 2 Mobile number

Parent Email *

Parent name (claimant) *

Parent DOB *

Parent Medicare Card Number *

Parent Medicare Card Position *

Parent Medicare Card Expiry *

Child Medicare Card Number *

Child Medicare Card Position *

Child Medicare Card Expiry *

GP Name & Address

GP telephone

Please describe the reason for your referral

What would be the best outcome you could imagine for your child?

How did you hear about rehab4rehab?