Participant Information

We ask that you complete the MRT participant information form below before your first visit to MoonRise. Your responses will help us in gathering information to provide you with the best assistance and ensure your safety.

If you prefer to download the form please click here: Download Participant Information Form.

Please email office@moonrisetherapeutics.org or call 802-299-8192 if you have any questions.

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Name *

First

Last

MoonRise Program You are Attending and Date(s) of Program:

special please you

What are some of your special interests/strengths?

What would you like to learn?

Communication; Attitude; Behavior- Please Check Area of Concern:

• Anxiety
• Impulsiveness
• Problem Solving
• Aggressiveness
• recall/memory
• Disorientation
• Seflf-Esteem
• Frustration Level
• Ability to Follow Directions
• Spatial Disorientation
• Slowness of Speech
• Distractibility
• Motivation
• Has a history of wandering or leaving safe areas without notice

Have you been diagnosed with any emotional health conditions? If yes, please specify:

Do you require andy accommodations for participating with MRT? If yes, please specify how we can accomodate your needs?

Other information that would be helpful to know:

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