Early Childhood Supports_ECT_Form

Early Childhood Support and Social Work Intake Form

Participant's First name

Last name

Birthday

Day

Month

Year

NDIS number

Single choice

Self managed

Plan Managed

Email to send invoices to

Address

Participant Goal 1 (or upload goals below)

Participant Goal 2

Participant Goal 3

Participant Goal 4

Participant Goal 5

Participant goals

Height and weight of rider (if applicable)

Please include if participant may be engaging in games on horseback.

Participant's experience with horses.

Additional information about the participant.

Please include diagnosis, allergies, fears, any other things we should be aware of)

Parent/ Guardian name

Phone

Address

Terms and ConditionsI have read the terms and conditions (service agreement).

I understand the 2026 fee structure: Program Structure & Fees

Session Length: 1 hour hands-on learning with the teacher Non Face-to-Face Support: 20 minutes of session planning, documentation, and communication with parents/carers

Hourly Rate: $193.99 (Total $258.64)

I acknowledge that I have read and understood the Insurance Waiver and that participation in activities involving horses carries inherent risks, which I understand and accept.

I acknowledge that while Alkira Adina Equestrian offers allied health services, it is not a disability riding service (such as Riding for the Disabled). Participants are required to be able to physically participate in programs without physical assistance.

I acknowledge that if the participant is under the age of 18 a parent or guardian must stay on the property for the duration of the session.

Date

Day

Month

Year

Signature (must be over 18)

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Name of person signing and relationship if participant is under 18.