Strides Equestrian Therapeutic Center Referral Form
Professional Referring
Today's Date
*
-
Month
-
Day
Year
Date
Name of person completing referral form
*
First Name
Last Name
Email
*
example@example.com
Organization & County
*
Phone Number
*
Please enter a valid phone number.
Program
*
CCS
CLTS
Other
Please specify other:
Client Information
Client Name
*
First Name
Last Name
Guardian Name (if a minor)
First Name
Last Name
MCI/Avatar #
*
Client's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Birth Date
-
Month
-
Day
Year
Date Picker Icon
Client's Email Address (Guardian's if client is a minor)
Client's Phone Number (Guardian's if client is a minor)
*
Please enter a valid phone number.
Gender
*
Male
Female
Preferred Pronouns
School Attending
Grade
Has an IEP
Yes
No
Reason for Referral
*
Presenting Issues/Diagnosis
*
Strides Interventions
*
ISDE/Skill Development (select WMR or ISDE)
Art Wellness (select WMR or ISDE)
Animal Wellness (select WMR or ISDE)
Yoga Wellness (select WMR or ISDE)
Equine Assisted Service (select WMR or ISDE)
Parent Coaching (select WMR, ISDE, or psycoedu.)
Service Array
*
Wellness Management and Recovery
Individual Skills Development and Enhancement
Individual and/or Family Psychoeducation
Indicate specific provider (if applicable)
Billing Agency
(Veterans Only)
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Submit
Should be Empty: