Returning Client

Trotting Horse Therapeutic Riding (THTR)

Returning Client Registration
Name*
Age*
Weight (Please note we offer both riding and non-riding options. For riding, we have a weight limit of 220 lbs due to the size and age of our horses.)*
Height*
Legally Responsible Party for Client and Billing:
Name
Relationship to Client
Cell Phone
Email
example@example.com
Mailing Address
Texts Ok?

YesNo
Do you give permission to use image (photo) of client in social media and advertising promoting Trotting Horse Therapeautic Riding?

YesNo
Is Client paying with Medicaid? (Must have Pre Authorization from Caseworker)

YesNo

THIS Section: Individuals paying with Medicaid
Caseworker Name
Caseworker Phone
Caseworker Email
example@example.com
I give THTR and/or Back Office Solutions permission to contact this caseworker for billing purposes

YesNo
*Note: THTR is covered under Montana Medicaid Community & Home Based Services. Your caseworker MUST provide us with a Prior Authorization Referral. ANY and ALL charges not covered by Medicaid will be billed and due by the client or guardian.

EMERGENCY CONTACT INFORMATION - REQUIRED for ALL

Please furnish the name and phone # of a contact person (if under 18, in addition to parent)
Name*
Relationship to Rider*
Address
Home Phone
Cell Phone*
Work Phone
Physician Name
Physician Phone
If any of the following has changed since we last saw you, please provide THTR with updated version:

Current Medication List

Allergies

IEP

Physical Restrictions

Current Season
What are client's or guardian's goals for this session, or for the long term? Please be specific.*
Client Availability This Season

We offer two 6-week sessions in the Spring and Fall. List ALL times available Mon-Fri this season
Which Session? You can do one or both. Please refer to website for dates.

Session 1Session 2
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Top Choice (we'll do our best!)
Should be Empty:

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Trotting Horse Therapeutic Riding (THTR)