Equine-Assisted Mental Health Interest Form
Potential Client Name:
*
First Name
Last Name
Potential Client Current Age
*
Potential Client Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Legally authorized parent or guardian - (if the potential client is a minor)
*
First Name
Last Name
Best contact phone:
*
-
Area Code
Phone Number
Best Contact Email
*
example@example.com
What is your Insurance Company? *Please note: The Insurances listed are currently accepted by Healing Reins. If you are covered by another insurance company, please call us at 541-382-9410 to discuss our options.
*
Aetna
Cigna
Firstchoice
PacificSource Health Plan
PacificSource Community Solution (OHP)
Providence
Blue Cross Blue Shield
N/A
Other
Are you interested in seeing a Mental Health Therapist Intern? Intern visits are charged at $45 per visit and cannot be billed to insurance.
*
Yes
No
Reason for seeking services/Anything else you like us to know
*
0/25
Submit
Should be Empty: