Riding out of your mind equestrian sport psychology services April Clay, M. Ed., Registered Psychologist



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Riding out of your mind equestrian sport psychology services

April Clay, M.Ed., Registered Psychologist


www.ridingoutofyourmind.com

www.outofyourmindcourses.com

Client Intake Form: Skype/Phone Sessions

Name: ________________________________ Date:__________


Date of Birth:______________ Age:________
Phone: home _____________ cell_____________
Address:________________________________________________________
Email:______________________________
Your Skype Name:____________________
Horse Sport: ________________ Coach:______________

Upcoming Competitive Events:_______________________________________




BRIEFLY DESCRIBE YOUR REASON FOR SEEKING HELP AT THIS TIME:

What times of the day or evening are you available for your session? What is your preference?

CONFIDENTIALITY

While we endeavor to protect your privacy at all times, communications over the Internet require the use of means that are beyond the control of the providers of this service, and may be subject to interception or loss. Therefore, BodyMindMotion cannot guarantee the security of any transmission of data across the Internet.___________________________________ (signature by email)



April Clay, R. Psych. www.bodymindmotion.com




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