Wild Hope Intake Form

First Name

Last Name

Date

Date of Birth

Cell Phone

Employer

Home Phone

Home Address

Responsible Party if Not Client:

DOB

SSN

Emergency Contact Name

Relationship

Emergency Contact Phone

Acknowledgment of Consent to Use & Disclose Your Information: This form is an agreement between you, and the 501©3 Embrace Equine Ministry, and its Wild Hope division. When we use the word “you” below, it can mean you, your child, a relative or other person if you have written your or his or her name here:

By signing this form you are acknowledging that you were given the opportunity to read, to discuss the content and to receive a copy of Embrace Equine Ministry’s HIPAA agreement. You are also agreeing to let us use your information here for the purposes of payment and operations. HIPAA explains, in more detail, your rights, and how we can use and share your information.

Please read this before you sign this consent form. After you have signed this consent, you have the right to revoke it (in writing to the Wild Hope Chief Executive Officer telling us you no longer consent) and we will comply with your wishes about using or sharing your information from that date on, but we may have already used or shared some information and cannot change that.

Relationship to Client:

Authority:

Select a date