Program Selection & Eligibility

Program Inquiry & Eligibility
Thank you for your interest in Equuvation's therapeutic and educational programs!

Please complete the following questionnaire to inquire about services and determine eligibility. A representative from our organization will be in touch within 48 hours upon submission. For specific questions, please email: equuvationinc@gmail.com

For all programs, additional client information may be requested.
Name
Town / State of Residence
I am inquiring about services/programs for (check all that may apply):

MyselfA child or children (under 18)An adult child (children over 18 - i.e. guardianship)Family UnitBusiness/Corporation or Organization/GroupOther
Client/Participant Name(s) (if different than above - i.e. child name)
Age of participant(s)/client(s) (only if under 18)
Email
example@example.com
Phone Number
Please enter a valid phone number.
Preferred method of contact (check all that may apply):

Phone CallTextEmailAny method of contact
I am interested in the following programs (check all that may apply):

Equine-facilitated Psychotherapy (EFP)Nature-based Talk Therapy (NBT)Therapeutic Horsemanship (TH)Equine-assisted Learning (EAL)Nature-based Occupational Therapy (NBOT)Unsure which program(s) I would like to exploreOther
I/we would like to participate (check all that may apply):

WeeklyEvery-other WeekMonthlyUnsureOther
Our preferred/available days and times currently are (check all that may apply):

Monday [AM - 9a-Noon]Monday [PM - 1p-6p]Tuesday [AM - 9a-Noon]Tuesday [PM - 1p-6p]Wednesday [AM - 9a-Noon]Wednesday [PM - 1p-6p]Thursday [AM - 9a-Noon]Thursday [PM - 1p-6p]Friday [AM - 9a-Noon]Friday [PM - 1p-6p]Saturday [AM - 9a-Noon]Saturday [PM - 1p-3p]
If my/our selected days/times are not available, would you like to be placed on our wait list?

YesNoUnsure
If my/our selected days/times are not available, would you like to be referred to another local counseling/therapeutic practice?

YesNoUnsure
Please expand on schedule details (i.e. "after school" hours, sports, preferred day and time, flexibility within schedule, etc.)
FINANCIAL (check all that may apply):

Private/self payScholarship/Financial Assistance (dependent on application and funds available)Insurance (if a paneled provider is available)Through a nonprofit partnership/grantCombination of the above optionsOther
REFERRAL – I/we heard about these programs and services as a result of (check all that may apply):

A referral from doctor or behavioral health professional*A referral from a teacher or counselor at school*An online search for services in our areaPsychologyToday.com profile searchA friend or family memberA presentation or special eventOther
*If you were referred by a medical professional or teacher, please elaborate (i.e. name, practice/school, reason for referral):
Anything else you would like us to know? Questions, comments, or additional details on participant(s) listed:
ELIGIBILITY VERIFICATION

I certify that the participant(s) I am inquiring for meet(s) the eligibility requirements outlined below. To be eligible for participation in equine-assisted activities through Equuvation or any of its affiliates, program applicants:
- Must be at least 2 yrs old (specific programs may have additional age requirements - i.e. clients looking for EFP service should be at least 8 years old);
- Must provide an accurate and verified health history if necessary for services;
- Must be willing to acknowledge and adhere to all Equuvation facility rules and regulations.
*We reserve the right to refuse any participant based on our ability to accommodate individual needs; and/or to refuse or discontinue any participant for whom the program is deemed by us not to be beneficial.
Signature

Clear
Today's Date

MonthDayYear
Date
Upon receipt of this questionnaire, a representative of Equuvation will be in touch within 48 hours. Should eligibility and availability of space within programs be confirmed, participants will be sent a program packet that will need to be completed before services can be provided.

Questions? equuvationinc@gmail.com
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Program Inquiry & Eligibility