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GRAND OPENING JUNE 7TH, 2026

Neurodiverse Program

Request Form

Participant's Name *

Preferred Name (if different)

Participant's Age *

Parent/Guardian Name

Gender (Optional)

Participant’s School (Optional)

Street Address

City

State

Country

Postal Code

_________________________

What is the participant’s comfort level around hores and dogs?

What should we know to help them feel safe and successful? (Optional: check any that apply and share anything helpful below.)

Takes time to warm up (may prefer to observe before engaging)

May feel overwhelmed by new environments or animals

Sensitive to sensory input (noise, touch, smells, movement)

Communicates in different ways (e.g., limited verbal, gestures, device)

May need support with physical boundaries or safety around animals

May need breaks or space to reset

Has physical or mobility considerations

What would the participant like to gain from this experience? (Select 2–3 priorities)

Confidence and self-trust

Emotional regulation and calm

Social connection and relationship-building

Communication (verbal or nonverbal)

Independence and responsibility

Body awareness and self-regulation

Comfort and confidence around animals

Sense of joy, engagement, and belonging

Does your student do best in:

One-on-one settings

Small groups

Either

_________________________

Contact First Name *

Contact Last Name

Contact Phone *

Contact Email

How would you prefere we reach out?

Call

Text

All

Thank you for sharing these insights with us—we look forward to getting to know you both.

A member of our team will reach out within 24 hours to learn more and plan a first visit that feels comfortable and positive.

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1900 Riverside Dr

Glendale, CA 91201

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GRAND OPENING JUNE 7TH, 2026

Neurodiverse Program

Request Form

_________________________

_________________________

Thank you for sharing these insights with us—we look forward to getting to know you both.

A member of our team will reach out within 24 hours to learn more and plan a first visit that feels comfortable and positive.

1900 Riverside Dr

Glendale, CA 91201

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