HTCC Registration Form

Registration Form

If you make an error when selecting services, please refresh the page.
What would you like to do?*

Register for a programMake a payment
Are you a new or existing client?*

NewExistingNew - Approved from Waitlist
Are you registering for a new program?*

Yes, I want to try something newNo, I am paying for more of the same services
Which service are you registering for?*
Which Equine Assisted Therapy service are you registering for?*
Which Therapy service are you registering for?*
Which of the following do you require?*

Group TherapyPrivate Group Therapy (Bring your own Group)
Which Fun Program are you registering for?*
Which Camp are you registering for?*
2023 SUMMER CAMP REGISTRATION
Please fill out this camp registration form. We will contact you to discuss your camper's enrollment and to process payment:

REGISTER HERE
2024 MARCH BREAK CAMP REGISTRATION
MARCH BREAK CAMP FOR 2023 IS FULL

Due to the limited spaces in our March Break Camps, these spots fill far in advance. We suggest securing your camper's spot early if you are interested.

If you are interested in our March Break 2024 Camp, please fill out this camp registration form. We will contact you to discuss your camper's enrollment and to process payment:

REGISTER HERE
Are you registering a minor child?*

YesNo
CLIENT INTAKE REGISTRATION
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Parent / Guardian Name

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Emergency Contact*
Emergency Contact's Phone Number *
Please enter a valid phone number.
Referring Professional
Referring Professional's Email Address
example@example.com
Referring Professional's Phone Number
Please enter a valid phone number.
Occupation & Employer *
How did you hear about us?*
Marital Status*
Who do you live with?*
Do you have children? If so, how many? Do they live with you?
If your minor children do not live with you, where do they live?
If you co-parent with a partner, or ex-partner, how do you get along?
Highest Level of Formal Education:*
If you completed a diploma/degree, which field?
Were you referred by your employer?*

YesNo
If so, are we authorized to speak to your employer?

YesNo
Name of Employer's Representative who we are authorized to speak to:
Do you have ongoing health issues?*

YesNo
If so, please tell us about these issues.
Do you have ongoing mental health issues?*

YesNo
If so, please tell us about these issues.
Do you have any diagnoses? Please list all (example: ADHD, cPTSD, ASD)*
Have you had any serious accidents, injuries or illnesses?*

YesNo
If so, please tell us more:
Do you have any issues with your sleeping patterns?*

YesNo
If so, please tell us about these issues.
How often do you exercise? *
Do you have any issues with your eating habits? If so, please explain.*
Besides family, approximately how many people can you really count on for friendship and emotional support?*

12345+
Have you been treated for any psychological or emotional problems?*

YesNo
If yes, what were you being treated for? How long was your treatment? What type of treatment?
How long ago did you receive the counseling or treatment?
If you are currently in counseling, what is the name and contact information of your therapist/counselor?
Do you give consent for a member of our team to speak with your therapist/counselor?

YesNo
Have you experienced serious depression, sadness, hopelessness, loss of interest, difficulty with daily functions? *
Have you experienced serious anxiety, tension, up-tightness, stress, excessive worry, or inability to relax? *
Please explain when the last time was and how often this occurs:
Have you experienced trouble concentration, understanding, or remembering different things? *
Please explain when the last time was and how often this occurs:
Have you experienced trouble controlling violent behaviour, including episodes of rage and violence? *
Please explain when the last time was and how often this occurs:
What usually triggers this behaviour?
Have you experienced thoughts of suicide? *
Have you attempted suicide?*

YesNo
If yes, please explain with a brief history of details:
Are you currently suicidal or thinking about suicide?*

YesNo
If yes, do you have a plan?

YesNo
Do you currently drink alcohol and/or use drugs?*
If yes, which substance? How much? How often?
Have you ever received treatment for alcohol or drug abuse/dependence?*

YesNo
If yes, please explain:
Would you like help with an addiction?*

YesNo
Who raised you? (i.e. mom and dad, grandparents, dad and partner, group home)*
How close are you currently to your parents/caregivers?*
How many siblings do you have and how close are you to your siblings?*
Did you experience traumatic events during your childhood? (i.e. deaths, abuse, etc.) Please explain:*
Did you ever see your care-givers psychologically or physically abuse one another? Please explain:*
Did you have any problems with anger or violent behaviour as a child or teenager? Please explain: *
Are there any other events that significantly impacted you in your childhood? (i.e. bully, significant death in the family family, etc.)*
Is there anything else that you think would be important for your counselor to know about your childhood? *
What are your top three goals for Equine Assisted Therapy?*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Our staff will contact you within 1 business days to discuss your needs.
WAITLIST - PLAY THERAPY

Please fill in the following information. Once submitted our staff will contact you when a therapy space becomes available. If the question does not pertain to you, please answer "Not Applicable" as all answers must be completed.
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Parent / Guardian Name

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Name*

First NameLast Name
Relationship to the Client*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
About The Client
Who Referred You to HTCC?*
Who does your child live with?*
If the child does not live with their family of origin, where do they live?
Does the child have ongoing mental or emotional health issues?*

YesNo
Does your child have any diagnoses? Please list all (example: ADHD, cPTSD, ASD [which level of ASD 1, 2 or 3], etc.)
Please list or share the challenges or concerns your child or family are experiencing and would like to work through in therapy?*
What are your top 3 goals for your child in Play Therapy?*
Is there anything else that you would like to share that would be important for our Therapy Team to know about your child?*
Our staff will contact you within 1 business days to discuss your needs.
WAITLIST - REINTEGRATION THERAPY

Please fill in the following information. Once submitted our staff will contact you when a space becomes available. If the question does not pertain to you, please answer "Not Applicable" as all answers must be completed.
Who were you referred by?*
Name*

First NameLast Name
Name of other parent *

First NameLast Name
Relationship to child(ren)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Place of birth*
Number of years at current address*
Occupation *
Employer name *
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Languages spoken at home*
PERTAINING TO OTHER PARENT
Name*

First NameLast Name
Relationship to child(ren)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of birth*

MonthDayYear
Date
Place of birth*
Number of years at current address*
Occupation *
Employer name*
Employer address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Languages spoken at home*
COUNSEL INFORMATION
Counsel Name*

First NameLast Name
Firm name *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
OTHER PARENT'S COUNSEL
Counsel Name*

First NameLast Name
Firm name *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
PERSONAL INFORMATION
Present Marital Status*

DivorcedSeparatedNever lived togetherMarried/Common Law
Are you living in the same home with the other parent?*

YesNo
Are you in a new relationship?*

YesNo
If yes, how long?
Does the other parent know of this relationship?*

YesNo
Are the children aware there is a new partner?*

YesNo
If not, is there a plan to introduce them?

YesNo
Is there a plan to move in together?*

YesNo
If yes, when?
Does your new partner have children?*

YesNo
If yes, indicate given names and ages:
RELATIONSHIP HISTORY
Date you met*

MonthDayYear
Date
Date of marriage/cohabitation *

MonthDayYear
Date
Date of separation *

MonthDayYear
Date
Date of divorce *

MonthDayYear
Date
Date of final separation?*

MonthDayYear
Date
Who made the decision to end the relationship?*
Do you have an interest in reconciling with the other parent?*
Reasons for final separation: *
List ALL person with whom you reside (including children,partners, relatives, caregivers etc.):*
Other children from previous or currentrelationships, other than above?*
Do your child(ren)have any special emotional, behavioural, educational or physical needs? If yes, please summarize briefly:*
PERSONAL & HEALTH HISTORY
Do you have a religious affiliation?*

YesNo
If so, please identify
Ifyou belong to a congregation, indicate the frequency you attend services:
When was the last time you attended services?
Is there a conflict with the other parent regarding religious observance?
Doyou have a chronic or recurrent health problem or physical disability?*

YesNo
If yes, please explain.
Are you currently on any prescribed medications?*

YesNo
If yes, list:
Do you use any drugs or medications other than as prescribed?*

YesNo
Has a physician ever prescribed medication for an emotional problem?*

YesNo
If so, explain:
Have you ever been hospitalized?*

YesNo
If yes, provide details:
Have you ever been under investigation by the police?*

YesNo
If yes, provide details:
Have you or a member of your family ever been charged, arrested and/or convicted of a crime?*

YesNo
If yes, provide details:
Have you or your family ever been under investigation by a child protection agency?*

YesNo
If yes, provide details:
List all mental health professionals and/or agencies with whom you or your child(ren) have had contact (eg., psychiatrist, psychologist, social worker, counselors). Please include full address, postal/zip code, dates seen, telephone, e-mail or fax. *
PARENTING SCHEDULE AND DECISION MAKING
Who currently has legal custody?*
Is there an Agreement or Court Order in place? (If so, provide a copy)*
File Upload

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What is the current parenting schedule? *
Do you have current child support arrangements? *
Is there a current dispute about the custody or parenting schedule? *
If yes, briefly describe the nature of the dispute and indicate when it began (the approximate date):
RELATIONSHIP WITH THE OTHER PARENT

During the relationship important decisions were made by (indicate you, other parent, or both):
House hold finances:*
Purchase/sale of family property *
Children’s education*
Children’s healthcare*
Children’s religious training*
Children’s extracurricular activities*
Were you able to discuss family issues openly with one another?*

YesNo
Were you are able to make decisions about the children cooperatively?*

YesNo
Were you able to discuss family issues openly with one another?*

YesNo
Were you are able to make decisions about the children co-operatively?*

YesNo
During the relationship:
1. How was childcare divided?*
2. Who took the children to school, day care,doctors and dentists appointments*
3. Who ate with the children, read to the children, played with the children, comforted the children when hurt?*
4. Did your children have a “favorite parent” at different times? How and why do you think this happened?*
5. Who did the children turn to for: homework, fight with friend, bad dream, scrapped knee, extra curricular activities choices? *
Communication:
1. How do you and your coparent communicate?*
2. Do you ever use the children to carry messages back and forth?*
3. How do you and your coparent resolve disputes?*
4. Do you ever make negative statements about your coparent in front of the children?*
5. Do your children have a relationship with your coparent’s family*
6. How important is the children’s other parent in their lives (1 = no importance, 2 = some importance, 3 = great importance)*
7. In an emergency, how well do you work with your coparent?*
9. How is information about your children’s events, activities, school meetings shared between coparents?*
Do you have any of the following concerns about the other parent ? (mark each option if the response is yes)*

Alcohol abuseDrug abuseEmotional abuse of childrenPhysical abuse of childrenSexual abuse of childrenInappropriate sexual behaviorPhysical healthCriminal behaviorPotential violent behaviorPotential suicide attemptChild kidnapping/ abduction?None of the above
If yes to any of the above, explain:
Is the other parent likely to express any of these concerns about you?*

YesNoDon't Know
If yes, provide details:
CONFLICT WITH OTHER PARENT
Have there been incidents of verbal and/or emotional abuse?*

YesNo
In the past six months?*

YesNo
At any time in the relationship?*

YesNo
If yes, provide details:
Have there been any incidents of physical abuse?*

YesNo
In the past six months?*

YesNo
If yes, provide details:
Have you called the police, as a result of abuse by the other parent?*

YesNo
If yes, explain:
Have charges ever been filed against you or the other parent?*

YesNo
If yes, explain
Has either parent ever had a restraining order?*

YesNo
If yes, provide details:
Is there currently a restraining order in effect, which you are involved in?*

YesNo
If yes, provide details:
Are you now, or have you even been on probation or parole?*

YesNo
If yes, explain:
Have there been charges filed against you forassault, domestic violence or stalking?*

YesNo
If yes, explain:
Have the children witnessed any incidents of physical, emotional or verbal abuse?*

YesNo
If yes, explain:
Do you have concerns about your child(ren)s safety with the other parent?*

YesNo
If yes, explain:
Are you fearful of the other parent for any reason?*

YesNo
If yes, please explain
Are you fearful of the other parent for any reason?*

YesNo
If yes, please explain:
Has the other parent threatened to deny you access to your child(ren)?*

YesNo
If yes, explain:
Has the other parent ever hit you or used any type of physical force against you?*

YesNo
If yes, please explain:
Has the other parent ever: emotionally or sexually abused you?*

Yes, EmotionallyNoYes, SexuallyNo
If yes, please explain:
Do you have concerns about meeting together with the other parent?*

YesNo
How would you describe your relation with the other parent? *
What is your understanding of the purpose of this counseling? *
How can this process be of assistance to you and your family:*
What are your goals for the counseling? What are your goals for your children?*
Who do you feel is the closest to you in your family?*
Who do you feel is the least close to you in your family? *
Describe the relationships between the siblings:
What do you believe to be the biggest struggle for your family right now? *
What needs to be different about your family to improve the situation for your child(ren)? *
What is your greatest parenting strength? *
What is your greatest parenting challenge? *
What is the other parent’s greatest parenting strength? *
What is the other parent’s greatest parenting challenge? *
What are your 3 most important concerns regarding: (a) Your child(ren): *
(b) Your family: *
(c) Your child(ren)’s other parent: *
What do you think are the 3 most important concerns the other parent has about you?*
On a scale of 1 to 7, with 1 being the LEAST important and 7 being the MOST important, how important do you think it is for your child to have contact with both of his/her parents?*
On a scale of 1 to 7, with 1 being the LEAST cohesive and 7 being the MOST cohesive, how cohesive do you think your family is right now?*
On a scale of 1 to 7, with 1 being the LEAST amount of involvement and 7 being the MOST amount of involvement, how much court involvement has your family had in the past year?*
Have you been court mandated to complete Reintegration Therapy?*

YesNo
If yes, please upload documents here*

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Our staff will contact you within 1 business days to discuss your needs.
WAITLIST: EQUINE STIMULATION

Please fill in the following information. Once submitted our staff will contact you when a space becomes available. If the question does not pertain to you, please answer "Not Applicable" as all answers must be completed.
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Parent / Guardian Name

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Name*

First NameLast Name
Relationship to the Client*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
About The Client
Who Referred You to HTCC?*
Who does your child live with?*
If the child does not live with their family of origin, where do they live?
Does the child have ongoing mental or emotional health issues?*

YesNo
Does your child have any diagnoses? Please list all (example: ADHD, cPTSD, ASD [which level of ASD 1, 2 or 3], etc.)
Please list or share the challenges or concerns your child or family are experiencing and would like to work through in equine stimulation?*
What are your top 3 goals for your child in Equine Stimulation?*
Is there anything else that you would like to share that would be important for our Team to know about your child?*
Our staff will contact you within 1 business days to discuss your needs.
WAITLIST - PRIVATE GROUP THERAPY

Please fill in the following information. Once submitted our staff will contact you when a therapy space becomes available. If the question does not pertain to you, please answer "Not Applicable" as all answers must be completed.
Name of Organizer *

First NameLast Name
Relationship to Group*
How many Participants?*
Are participants related?*

YesNo
If, yes who?*
Name and Age of Participants*
What concerns would your group like to target?*
How many weeks would you like the program to run?*
Our staff will contact you within 1 business days to discuss your needs.
WAITLIST - EQUINE ASSISTED THERAPY

Please fill in the following information. Once submitted our staff will contact you when a therapy space becomes available. If the question does not pertain to you, please answer "Not Applicable" as all answers must be completed.
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Is the client a minor child?*

YesNo
Parent / Guardian Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Name*

First NameLast Name
Relationship to the Client*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
About The Client
Who Referred You to HTCC?*
Who do you live with?*
Marital Status*
Do you have any children? If so, how many? Do they live with you? If your minor children do not live with you, where do they live?
If you co-parent with a partner, or ex-partner, how do you get along?
Do you have ongoing mental or emotional health issues?*

YesNo
If so, please tell us about these issues?*
Do you have any diagnoses? Please list all (example: ADHD, cPTSD, ASD [which level of ASD 1, 2 or 3], etc.)
Have you experienced thoughts of suicide?*

YesNo
Have you ever attempted suicide?*

YesNo
If yes, please explain with a brief history of details.
Are you currently suicidal of thinking about suicide?*

YesNo
If yes, do you have a plan?*

YesNo
We are here to help but we are not a crisis centre.

If you are experiencing a mental health or addictions related crisis:

Contact your doctor;

Go to the nearest hospital;

Call 911 or Telehealth Ontario at 1-866-797-0000
Please list or share the challenges or concerns you are experiencing and would like to work through in therapy?*
What are your top 3 goals for Equine-Assisted Therapy?*
Is there anything else that you would like to share that would be important for our Therapy Team to know about you/ or your child?*
Our staff will contact you within 1 business days to discuss your needs.
WAITLIST: ASD THRIVE PROGRAM

Please fill in the following information. Once submitted our staff will contact you when an ASD Thrive space becomes available. If the question does not pertain to you, please answer "Not Applicable" as all answers must be completed.
Name of Caregiver*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Level of ASD Diagnosis*

123No formal diagnosisI don't know
Is your child verbal?*

YesNo
Our staff will contact you within 1 business days to discuss your needs.
WAITLIST: ABA THERAPY

Please fill in the following information. Once submitted our staff will contact you when an ABA therapy space becomes available. If the question does not pertain to you, please answer "Not Applicable" as all answers must be completed.
Name of Caregiver*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Level of ASD Diagnosis*

123
Is Your Child Verbal?*

YesNo
Which Schedule would you prefer? (Select all applicable)*

Morning (8:30 - 12:30)Afternoon (12:30 - 4:30)All daySocial Skills (4:30 - 6:00)
When do you need services for?*

ImmediatelyWithin the next 30 daysWithin the next 60 daysLonger than 60 daysFlexible
Our staff will contact you within 1 business days to discuss your needs.
Birthday Party Forms

Please fill out these forms and on of our staff will contact you within one business day to confirm availability and schedule your party.
Organizer's Name*

First NameLast Name
Relationship to Birthday Person*
Birthday Person's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Is this a surprise?*

YesNo
Gender*

Non-binaryFemaleMale
Please list the names and ages of guests.*
Will adults be participating in the event?*

YesNo
Will you be bringing a cake to share with the participants AFTER the event?*

YesNo
For your convenience, we also offer these products and services for an addition cost. Please let us know which you are interested in:*

Decorating (table and reception area)Drinks (water, pop, and juices)Pizza (2 large pizzas with 2 toppings each)CakesBalloons (for the birthday person to take home with them)None of the above
Additional information that you would like HTCC to know:*
Our staff will contact you within 1 business days to discuss your needs.
Corporate Event
Organizers Name*

First NameLast Name
Company*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What Type of An Event Are you Interested In?*

Group TherapyTeam BuildingLeadershipFunLearn Specific Psychosocial Skills
Tell us more about what you are looking for*
How many attendees?*
Preferred Date of Event - 1st Choice*

MonthDayYear
Date
Preferred Date of Event - 2nd Choice*

MonthDayYear
Date
Preferred Date of Event - 3rd Choice*

MonthDayYear
Date
Our staff will contact you within 1 business days to discuss your needs.
Stable Minds School Program
Organizers Name*

First NameLast Name
School*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What Type of An Event Are you Interested In?*

1-Day Program6-Week ProgramOther
Tell us more about what you are looking for (Also add grades and abilities of students, and how many teachers will attend)*
How many attendees?*
Preferred Date of Event - 1st Choice*

MonthDayYear
Date
Preferred Date of Event - 2nd Choice*

MonthDayYear
Date
Preferred Date of Event - 3rd Choice*

MonthDayYear
Date
Our staff will contact you within 1 business days to discuss your needs.
Terms & Conditions

In order to keep all of our clients safe, and to ensure that clients understand our policies and procedures, we ask that everyone attending our programs understand and agree to the below terms and conditions.
WARNING: THIS AGREEMENT WILL AFFECT YOUR LEGAL RIGHTS. READ IT CAREFULLY!

Appointments and Facility
The event or session can be canceled 48 hours before the event/session begins via their client portal at www.horsetherapycanada.com

The Client must arrive at the event 10 minutes before the event/session in order to complete registration and sign-up protocols.

The Client’s session will begin at the time they have scheduled. If the client arrives early, the client is asked to remain in the vehicle until the session begins. The client can meet their therapist at the Horse Therapy Centre of Canada Trailer to answer COVID-19 screening questions at the time of their session.

Any event/session, which starts later than scheduled for any reason, will finish according to schedule (i.e. the event/session will be shorter).

It is imperative that drivers/parents/guardians are on time to pick up their minor child. Therapists are unable to wait with your child to ensure their safety for pickup, if you are late.

In the event that a minor child's driver is late for pickup, the parent/guardian will be charged for the therapist’s time at the rate of $250/hr, a 1 hour minimum will be charged. The next session will not be scheduled until this fee has been paid.

Horse Therapy Centre of Canada has the right to make changes in the Event Timetable, in particular: change the Instructor, replace the Event with another one, or cancel the Event. Such changes only happen in exceptional situations and are not standard practice.

Horse Therapy Centre of Canada has the right to change the location of services within a 30 km radius. Such changes only happen in exceptional situations and are not standard practice.

Client Accountability
The Client and/or Parent/Guardian is obliged to inform the instructor about any health issues and limitations which may affect the Client’s safety and restrict the possibility of performing physical activities.

The instructor has the right to refuse participation to the Client if the Client arrived late and/or is disruptive to the activities. No refunds will be provided in either circumstance.

The instructor may ask the Client to leave the event if they decide that the Client’s behaviour is violating public order, good manners, or Company Terms and Conditions. The instructor may ask the Client to leave if the Client’s health condition is dangerous for the client himself or for other attendees. No refunds will be provided.

The client and/or parent/guardian understands that there is a Zero Tolerance Policy toward aggressive and abusive behaviour towards Horse Therapy Centre of Canada’s staff members, volunteers, program participants, and animals. This includes any abusive or threatening comments, aggressive gestures, physical contact, verbal abuse, and any other behaviour that is deemed unsafe.

I understand that I / my child can be removed from the program with immediate effect and will not receive a refund.

During the event, the Client is obliged to wear appropriate clothing and footwear (no open-toe shoes).

Privacy and Sharing of Information
The Client understands and agrees that the Horse Therapy Centre of Canada regularly uses different forms of medias (photograph, video, etc.) to document the programs. These medias can and will be used by the Horse Therapy Centre of Canada on different media sites (including but not limited to: the company website, Facebook, Instagram, YouTube) and/or for broadcasting on television or radio as determined by the Horse Therapy Centre of Canada.

I authorize the Horse Therapy Centre of Canada and its associated health professionals to collect personal and medical information as documented in my digital file, stored in the Horse Therapy Centre of Canada’s booking system.

I authorize the Horse Therapy Centre of Canada and its associated health professionals to communicate with all parties indicated within the online client profile, as deemed necessary for my beneficial treatment.

I understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission

I understand that if I want the Horse Therapy Centre of Canada to release my information to any third parties, I must fill out the Release of Information form.

No-Refund Policy:
All sales are final. We do not give refunds for canceled or rescheduled events/sessions. The Horse Therapy Centre of Canada reserve all rights to reschedule sessions/events due to low attendance, weather occurrences or extenuating circumstances.

In the rare event that a refund is approved by the Horse Therapy Centre of Canada due to extenuating circumstances, a $250 administrative fee will be charged.
WARNING: THIS AGREEMENT WILL AFFECT YOUR LEGAL RIGHTS. READ IT CAREFULLY!

Appointments and Facility
The event or session can be canceled 48 hours before the event/session begins via their client portal at www.horsetherapycanada.com

The Client must arrive at the event 10 minutes before the event/session in order to complete registration and sign-up protocols.

The Client’s session will begin at the time they have scheduled. If the client arrives early, the client is asked to remain in the vehicle until the session begins. The client can meet their therapist at the Horse Therapy Centre of Canada Trailer to answer COVID-19 screening questions at the time of their session.

Any event/session, which starts later than scheduled for any reason, will finish according to schedule (i.e. the event/session will be shorter).

It is imperative that drivers/parents/guardians are on time to pick up their minor child. Therapists are unable to wait with your child to ensure their safety for pickup, if you are late.

In the event that a minor child's driver is late for pickup, the parent/guardian will be charged for the therapist’s time at the rate of $250/hr, a 1 hour minimum will be charged. The next session will not be scheduled until this fee has been paid.

Horse Therapy Centre of Canada has the right to make changes in the Event Timetable, in particular: change the Instructor, replace the Event with another one, or cancel the Event. Such changes only happen in exceptional situations and are not standard practice.

Horse Therapy Centre of Canada has the right to change the location of services within a 30 km radius. Such changes only happen in exceptional situations and are not standard practice.

Client Accountability
The Client and/or Parent/Guardian is obliged to inform the instructor about any health issues and limitations which may affect the Client’s safety and restrict the possibility of performing physical activities.

The instructor has the right to refuse participation to the Client if the Client arrived late and/or is disruptive to the activities. No refunds will be provided in either circumstance.

The instructor may ask the Client to leave the event if they decide that the Client’s behaviour is violating public order, good manners, or Company Terms and Conditions. The instructor may ask the Client to leave if the Client’s health condition is dangerous for the client himself or for other attendees. No refunds will be provided.

The client and/or parent/guardian understands that there is a Zero Tolerance Policy toward aggressive and abusive behaviour towards Horse Therapy Centre of Canada’s staff members, volunteers, program participants, and animals. This includes any abusive or threatening comments, aggressive gestures, physical contact, verbal abuse, and any other behaviour that is deemed unsafe.

I understand that I / my child can be removed from the program with immediate effect and will not receive a refund.

During the event, the Client is obliged to wear appropriate clothing and footwear (no open-toe shoes).

Privacy and Sharing of Information
The Client understands and agrees that the Horse Therapy Centre of Canada regularly uses different forms of medias (photograph, video, etc.) to document the programs. These medias can and will be used by the Horse Therapy Centre of Canada on different media sites (including but not limited to: the company website, Facebook, Instagram, YouTube) and/or for broadcasting on television or radio as determined by the Horse Therapy Centre of Canada.

I authorize the Horse Therapy Centre of Canada and its associated health professionals to collect personal and medical information as documented in my digital file, stored in the Horse Therapy Centre of Canada’s booking system.

I authorize the Horse Therapy Centre of Canada and its associated health professionals to communicate with all parties indicated within the online client profile, as deemed necessary for my beneficial treatment.

I understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission

I understand that if I want the Horse Therapy Centre of Canada to release my information to any third parties, I must fill out the Release of Information form.

No-Refund Policy:
All sales are final. We do not give refunds for canceled or rescheduled events/sessions. The Horse Therapy Centre of Canada reserve all rights to reschedule sessions/events due to low attendance, weather occurrences or extenuating circumstances.

In the rare event that a refund is approved by the Horse Therapy Centre of Canada due to extenuating circumstances, a $250 administrative fee will be charged.
Client / Parent / Guardian Signature*

Clear
Printed Name*

First NameLast Name
Date Signed*

MonthDayYear
Date
ACKNOWLEDGMENT OF RISK AND RELEASEOF LIABILITY

For Participants Over the Age of Majority in the Province or Territory in which the Equine Activities are Provided by the Host
WARNING: THIS AGREEMENT WILL AFFECT YOUR LEGAL RIGHTS. READ IT CAREFULLY!

Every Person Must Read and Understand this Waiver Before Participating in Equine Activities

The following waiver of all claims, release from all liability, assumption of all risks, agreement not to sue and other terms of this agreement are entered into by me (the Participant) with and for the benefit of Horse Therapy Centre of Canada Inc., its directors, officers, employees, volunteers, business operators, agents and site property owners or lessees (collectively the "Host"). Without limiting the generality of the foregoing, "Equine Activities" includes but is not limited to meditating with horses, youth leadership with horses, trail rides, equine assisted therapy, goat therapy, hippotherapy, therapeutic riding and riding instructions provided by Horse Therapy Centre of Canada Inc. to the Participant.

Read each item below before signing this form:

1. I am aware that there are inherent dangers, hazards and risks (collectively "Risks") associated with "Equine Activities" and injuries resulting from these "Risks" are a common occurrence. I am aware that the "Risks" of "Equine Activities" mean those dangerous conditions which are an integral part of "Equine Activities", including but not limited to: (a) the propensity of any equine to behave in ways that may result in injury, harm or death to persons on or around them and to potentially collide with, bite or kick other animals, people or objects; (b) the unpredictability of an equine's reaction to such things as sounds, sudden movement, tremors, vibrations, unfamiliar objects, persons or other animals and hazards such as subsurface objects; (c) the potential for other participants to behave in a negligent manner that may contribute to injury to themselves or others, including failing to act within their abilities to maintain control over an equine.

2. I freely accept and fully assume all responsibility for all "Risks" and possibilities of personal injury, death, property damage or loss resulting from my participation in "Equine Activities".

3. I agree that although the "Host" has taken steps to reduce the "Risks" and increase the safety of the "Equine Activities", it is not possible for the "Host" to make the "Equine Activities" completely safe. I accept these "Risks" and agree to the terms of this waiver even if the "Host" is found to be negligent or in breach of any duty of care or any obligation to me in my participation in "Equine Activities".

4. In addition to consideration given to the "Host" for my participation in "Equine Activities", I and my heirs, next of kin, executors, administrators and assigns (collectively my "Legal Representatives") agree: (a) to waive all claims that I have or may have in the future against the "Host"; (b) to release and forever discharge the "Host" from all liability for any personal injury, death, property damage, or loss resulting from my participation in the equine activity due to any cause, including but not limited to negligence (failure to use such care as a reasonably prudent and careful person would use under similar circumstances), breach of any duty imposed by law, breach of contract or mistake or error in judgment of the "Host"; and (c) to be liable for and to hold harmless and indemnify the "Host" from all actions, proceedings, claims, damages, costs demands, including court costs and costs on a solicitor and own client basis, and liabilities of whatsoever nature or kind arising out of or in any way connected with my participation in "Equine Activities".

5. I agree that this waiver and all terms contained herein are governed exclusively and in all respects by the laws of the Province or Territory of Canada in which the "Equine Activities" are provided by the "Host". I hereby irrevocably submit to the exclusive jurisdiction of the courts of that Province or Territory of Canada and I agree that no other court can exercise jurisdiction over the terms and claims referred to herein. Any litigation to enforce this waiver will be instituted in the Province or Territory of Canada in which the "Equine Activities" are provided by the "Host".

6. I confirm that I have had sufficient time to read and understand this waiver in its entirety. I understand that this agreement represents the entire agreement between myself and the "Host", and it is binding on myself and my "Legal Representatives".

7. I confirm that I have reached the age of majority in the province in which I am participating in "Equine Activities".

I, the below-signed participant, swear that I have read all items above and I understand and agree to all items:
Name of Participant*

First NameLast Name
Date of Birth Of Participant*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client / Parent / Guardian Signature*

Clear
Signed On*

MonthDayYear
Date
ACKNOWLEDGMENT OF RISK AND RELEASEOF LIABILITY

For Participants Under the Age of Majority in the Province orTerritory in which the Equine Activities are Provided by the Host
WARNING: THIS AGREEMENT WILL AFFECT YOUR LEGAL RIGHTS. READ IT CAREFULLY!

The Parent/Guardian Must Read and Understand this Waiver Prior to Infant Participating in Equine Activities

The following waiver of all claims, release from all liability, assumption of all risks, agreement not to sue and other terms of this agreement are entered into by me on behalf of the Infant Participant named below with and for the benefit of Horse Therapy Centre of Canada Inc., its directors, officers, employees, volunteers, business operators, agents, and site property owners or lessees (the “Host”). Without limiting the generality of the foregoing, “Equine Activities” includes but is not limited to meditating with horses, youth leadership with horses, trail rides, equine assisted therapy, goat therapy, hippotherapy, therapeutic riding and riding instructions provided by the "Host" to the Infant Participant.

Read all of the below items and sign below after understanding each item:

1. I am the Parent/Guardian of the Infant Participant and am executing this waiver on behalf of the Infant Participant in my capacity as Parent/Guardian and with the intent that his waiver be binding on myself and the Infant Participant for all legal purposes.

2. I am aware that there are inherent dangers, hazards and risks (“Risks”) associated with "Equine Activities" and injuries resulting from these "Risks" are a common occurrence. I am aware that the "Risks" of "Equine Activities" mean those dangerous conditions which are an integral part of "Equine Activities", including but not limited to: (a) the propensity of any equine to behave in ways that may result in injury , harm or death to persons on or around them and to potentially collide with, bite or kick other animals, people or objects; (b) the unpredictability of an equine’s reaction to such things as sounds, sudden movement, tremors, vibrations, unfamiliar objects, persons or other animals and hazards such as subsurface objects; and (c) the potential for other participants to behave in a negligent manner that may contribute to injury to themselves or others, including failing to act within their abilities to maintain control over an equine.

3. I freely accept and fully assume all responsibility for all "Risks" and possibilities of any and all personal injury, death, property damage or loss resulting from the Infant Participant’s participation in "Equine Activities".

4. I agree that although the "Host" has taken steps to reduce the "Risks" and increase the safety of the "Equine Activities", it is not possible for the "Host" to make the "Equine Activities" completely safe. I accept these "Risks" and agree to the terms of this waiver on behalf of the Infant Participant, even if the "Host" is found to be negligent or in breach of any duty of care or any obligation to myself or the Infant Participant in the Infant’s participation in "Equine Activities".

5. In addition to consideration given to the "Host" for the Infant Participant’s participation in "Equine Activities", I and my heirs, next of kin, executors, administrators and assigns, as well as the Infant Participant and his/her heirs, next of kin, executors, administrators and assigns (collectively our “Legal Representatives”) agree: (a) to waive all claims that the Infant Participant has or may have in the future against the "Host"; (b) to release and forever discharge the "Host" from all liability for personal injury, death, property damage, or loss that I, the Infant Participant, or our "Legal Representatives" might suffer as a result of the Infant Participant’s participation in "Equine Activities" due to any cause, including but not limited to negligence (failure to use such care as a reasonably prudent and careful person would use under similar circumstances), breach of any duty imposed by law, breach of contract or mistake or error in judgment of the "Host"; and (c) to be liable for and to hold harmless and indemnify the "Host" from all actions, proceedings, claims, damages, costs demands, including court costs and costs on a solicitor and own client basis, and liabilities of whatsoever nature or kind arising out of or in any way connected with the Infant's participation in "Equine Activities".

6. I agree that this waiver and all terms contained herein are governed exclusively and in all respects by the laws of the Province or Territory of Canada in which the "Equine Activities" are provided by the "Host". I hereby irrevocably submit to the exclusive jurisdiction of the courts of that Province or Territory of Canada and I agree that no other court can exercise jurisdiction over the terms and claims referred to herein. Any litigation to enforce this waiver will be instituted in the Province or Territory of Canada in which the "Equine Activities" are provided by the "Host".

7. I confirm that I have had sufficient time to read and understand this waiver in its entirety. I understand that this agreement represents the entire agreement between the "Host", myself as Parent/Guardian, and the Infant Participant, and it is binding on myself, the Infant Participant and our "Legal Representatives".

I, the Parent/Guardian of the participant, swear that I have read all of the above items and understand and agree to all items:
Infant Participant's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature of Parent/Guardian*

Clear
Date Signed*

MonthDayYear
Date
Payment
How would you like to pay:*

Credit Card (3% processing fee)Email Money TransferDrop off Cash at the office
Email Money Transfer Instructions:

Please fill out the Order Form below and send an email money transfer to office@horsetherapycanada.com for the full amount that is shown on the subtotal on the Order Form.
Cash Drop-Off Instructions:

Please fill out the Order Form below and bring the full amount that is shown on the subtotal on the Order Form to:

15443 Ninth Line, Stouffville, ON

Office Hours: Monday - Friday: 10:00 am - 6:00 pm
Please submit the order form below. Our administrative staff will contact you within 1 business day to schedule your appointments.
My Products*
Categories:All

All
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Equine Assisted Therapy - 5 Sessions
$1,050.00CAD



Equine Assisted Therapy - 10 Sessions
$1,890.00CAD



Equine Assisted Couples Therapy - 5 Sessions
$1,425.00CAD



Paint with Ponies - Adult
$65.00CAD



Play Therapy5 Sessions
$725.00CAD



Equine Assisted Family Therapy - 5 Sessions
$1,425.00CAD Quantity



Women's Grief & Healing After Pregnancy and/or Infant Loss (PAIL)6-week program
$390.00CAD



Parents With Oppositional Kids/Teens6-week program
$390.00CAD



Social Anxiety in Youth6-week program
$390.00CAD



Family Grief & Healing After Pregnancy and/or Infant Loss (PAIL)6-week program
$390.00CAD



ABA Therapy - Half Day1 week of half-day ABA / IBI Services
$1,200.00CAD Quantity



ABA Therapy - Full Day1 week of full-day ABA /IBI Services
$2,400.00CAD Quantity



ASD Social Group$55 per session when 10 sessions purchased
$65.00CAD Quantity



ASD Thrive Session5 sessions
$400.00CAD



Equine Assisted Therapy Intake Appointment
$140.00CAD



Full Moon Bonfire Meditation
$50.00CAD



Family Paint with Ponies (6+)
$49.50CAD



Pony Pals (Ages 5+)
$22.60CAD



Family Time with Ponies
$42.50CAD



Equine Assisted Therapist Certification Program COST: $5639 DEPOSIT: $2819.50 due upon registration. Remaining investment due by 90 days before start date
$2,189.50CAD



Equine Assisted Learning Facilitator Certification Program COST: $4250.00 DEPOSIT: $2125.00 due upon registration. Remaining investment is due 90 days before the program
$2,125.00CAD



Group Horsemanship (12+)Learn how to handle and care for horses in a group setting. These are fun and educational classes. 12+
$45.00CAD



Private Horsemanship LessonsPrivate 1:1 Horsemanship lessons will teach you how to handle, care for and manage horses. All ages.
$65.00CAD



12 Group Horsemanship LessonsEvery 3 months 12 Private 1:1 Horsemanship Lessons.$50 / lesson. Save $180
$600.00CAD



5 Group Horsemanship LessonsEvery 5 weeks
$200.00CAD



5 Private 1:1 Horsemanship LessonsEvery 5 weeks
$290.00CAD



Case Conference This service is for one staff member from HTCC to have a case conference with a working professional or agency. This type of service is purchased by the HTCC client.
$125.00CAD



$40 Gift Certificate
$40.00CAD



$75 Gift Certificate
$75.00CAD



$100 Gift Certificate
$100.00CAD



$210 Gift Certificate
$210.00CAD



$1785 Gift Certificate
$1,785.00CAD



Equine Stimulation 5 Sessions
$350.00CAD



Product Name
$ Free CAD



Subtotal

$0.00CAD

Tax

$0.00CAD

Total

$0.00CAD
Credit Card Number*
Expiry Date*
CVC*
Postal Code*
I agree that HTCC can charge my credit card for the amount that I have indicated on the Order Form above. I understand that HTCC will charge my card for an additional 3% Service Charge to the fees. I have read and agree to HTCC refund policy.*

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Registration Form

2023 SUMMER CAMP REGISTRATION

2024 MARCH BREAK CAMP REGISTRATION

CLIENT INTAKE REGISTRATION

WAITLIST - PLAY THERAPY

Emergency Contact

About The Client

WAITLIST - REINTEGRATION THERAPY

PERTAINING TO OTHER PARENT

COUNSEL INFORMATION

OTHER PARENT'S COUNSEL

PERSONAL INFORMATION

RELATIONSHIP HISTORY

PERSONAL & HEALTH HISTORY

PARENTING SCHEDULE AND DECISION MAKING

RELATIONSHIP WITH THE OTHER PARENT

During the relationship:

Communication:

CONFLICT WITH OTHER PARENT

WAITLIST: EQUINE STIMULATION

Emergency Contact

About The Client

WAITLIST - PRIVATE GROUP THERAPY

WAITLIST - EQUINE ASSISTED THERAPY

Emergency Contact

About The Client

WAITLIST: ASD THRIVE PROGRAM

WAITLIST: ABA THERAPY

Birthday Party Forms

Corporate Event

Stable Minds School Program

Terms & Conditions

ACKNOWLEDGMENT OF RISK AND RELEASEOF LIABILITY

ACKNOWLEDGMENT OF RISK AND RELEASEOF LIABILITY

Payment

Please submit the order form below. Our administrative staff will contact you within 1 business day to schedule your appointments.