Colorado Therapeutic Riding Center Participant Application

Today's Date*

Date

Participant Name*

First NameLast Name

Participant Preferred Name:

Participant Preferred Pronouns:*

Birthdate*

Date

Age*

Gender*

Height*

Weight*

Pounds (limit 200)

Race/Ethnicity

(Optional)

Address*

Street Address

Street Address Line 2

CityState

Zip Code

How did you hear about us?

Previous Riding Experience*

Describe Previous Riding Experience if applicable

Please List Times that MIGHT Work to Participate in CTRC Programs*

Therapeutic Horsemanship is taught by a PATH Intl Certified Therapeutic Riding Instructor and is conducted in a group or semi-private setting. These sessions are aimed to teach participants horsemanship, and by extension, life skills. Benefits of Therapeutic Horsemanship include the development of cognitive, physical and social skills. Group classes are organized by age, type of disability and level of riding skill. Therapeutic Horsemanship may be offered in both mounted, and unmounted sessions depending on the need of our participants.

Equine Assisted Therapy (formerly Hippotherapy) is conducted by a licensed therapist, who is registered with the American Hippotherapy Association (AHA). CTRC contracts Occupational Therapists, Speech Therapists and Physical Therapists. Each participant works one-on-one with their therapist allowing for intensive therapy directed specifically at the participant’s individual therapy needs and goals. These sessions should be considered the same as a clinical setting, but using the horse as a modality for the therapy.

Equine Assisted Mental Health is an experiential psychotherapy session conducted by a licensed mental health professional (LPCC) who also is certified through PATH Intl as an Equine Specialist in Mental Health and Learning (ESMHL). A horse is used in conjunction with clinical therapy on the ground (not mounted). Horses mirror our emotional state and provide us with honest, in the moment, feedback. The presence and connection with the horse is used as a metaphor for our personal lives, relationships, and past experiences. These psychotherapy sessions may be conducted one-on-one or in a group setting.

Program Interested in:*

Therapeutic HorsemanshipEquine Assisted TherapyEquine Assisted Mental Health

Preferred Contact*

First NameMiddle NameLast Name

Relationship*

Preferred Phone

Primary E-mail*

Alternate Email

example@example.com

Phone*

Alternate Phone Number

Preferred Contact Address*

Street Address

Street Address Line 2

CityState

Zip Code

Participant Diagnosis*

Physical Skills the participant is able to demonstrate*

Describe General Balance*

Describe Muscle Tone*

Please list and explain ANY assistive devices that the participant may use at home or school (e.g. walker, communication device):

Notes on Hearing or Vision Impairments

Experience Wearing a Helmet*

(biking, skiing, etc)

Wearing a helmet may be a possible challenge*

Educational and Cognitive Skills the Participant is able to demonstrate*

Social Skills the Participant is able to demonstrate*

Language Skills the Participant is able to demonstrate*

Please describe Participant's personality and strengths*

Psychological, emotional, behavioral, social issues

Any other special things we should know?

Horsemanship Goals

Therapeutic Goals

Recreational Goals

Social Goals

Any Other Goals

This form was filled out by*

Signature*

member_status

Campaign_ID

Participant Information

Services offered at CTRC

Contact Information

Participant Diagnosis and Skill Assessment

Goals while at CTRC