Strides Referral Form

Today's Date

Date

Name of person completing referral form

First NameLast Name

Email

example@example.com

Organization & County

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Program

Other

Please specify other:

Client Name

First NameLast Name

Legal Guardian Name (Must Include if a minor)

First NameLast Name

Relation to Client

MCI/Avatar #

Client's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Client's Birth Date

MonthDayYear

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.Format: (000) 000-0000.

Gender

Preferred Pronouns

School Attending

Current Grade

Age

Has an IEP

Reason for Referral

Trauma History

Presenting Issues/Diagnosis

Releases that are needed

Please email Heidi Lenz heidi@stridescenter.com Treatment Plan (when updated with the appropriate provider), ROI, Assessment (CANS), and Crisis Plan (If needed). Thank you

Equine Assisted Services
Strides offers Equine Assisted Services to support clients in reaching individualized goals through structured interactions with horses. All services are trauma-informed and provided within each provider’s education, training, certification, licensure, and professional scope.

Equine Assisted Learning (EAL)
Equine Assisted Learning focuses on learning and practicing skills through interactions with horses. Goals may include emotional regulation, communication, problem-solving, confidence, boundaries, relationships, and other life skills.

EAL is typically provided by one qualified Equine Specialist.

Equine Assisted Coaching
Equine Assisted Coaching focuses on individualized goals, personal growth, motivation, behavior change, relationships, self-awareness, and emotional regulation.

Coaching may be provided by an Equine Specialist who also holds a Trauma-Informed Coaching certification or by a master’s-level provider, depending on the client’s needs and goals. An additional Equine Specialist may be included when appropriate.

Equine Assisted Coaching is non-clinical and is not psychotherapy

Equine Assisted Counseling/Coaching
Equine Assisted Counseling integrates horses into counseling to address identified mental-health needs and treatment goals. Sessions may support clients with emotional regulation, trauma recovery, attachment and relationship patterns, anxiety, depression, coping skills, communication, boundaries, and other clinical concerns.

Equine Assisted Counseling is provided by a qualified mental-health professional practicing within their education, training, licensure, and professional scope. A qualified Equine Specialist may also participate to support safe, intentional interactions between the client and horse.

Choosing a Service
The appropriate service and provider are determined by the client’s goals, clinical needs, and required level of support. Strides will match each client with a provider—or provider team—whose qualifications and scope of practice align with those needs.

Not sure which option fits? Please contact Strides, and we will help determine the most appropriate service and provider.

Whichever Equine Assisted Service is Available

Equine Assisted Coaching/Counseling Mental Health Provider + Equine Specialist + Equine

Equine Assisted Coaching Trauma Informed Care Coach + Equine

Equine Assisted Learning Trauma Informed Care Coach + Equine

Other

Art Wellness with Justin or Jamie

Yoga Wellness/Mindfulness with Jolyn or Jamie

Parent Coaching

Skill Development (Mentoring) Visit www.stridescenter.com for provider Biography's

Indicate specific provider (if applicable)

Trauma & Teens Support Group

Transgender Support Group

HPR & Emotional Support Group

Service Array

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Strides Equestrian Therapeutic Center Referral Form

Client Information

StrideRise Support Groups

Billing Agency