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.

Program*

CCSCLTSOther

Please specify other:

Client Name*

First NameLast Name

Guardian Name (if a minor)

First NameLast Name

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.

Gender*

MaleFemale

Preferred Pronouns

School Attending

Grade

Has an IEP

YesNo

Reason for Referral*

Presenting Issues/Diagnosis*

Equine Assisted Services are designed to address a variety of client needs, with each area aligned to the provider's credentials and degree level and grounded in trauma-informed care principles.

Equine Assisted Learning focuses on enhancing personal development, life skills, and self-awareness through interactions with horses, supported by the provider’s equine skills and trauma-informed training. This service includes only one provider in the session.

Equine Assisted Coaching emphasizes goal-setting, motivation, and performance enhancement, addresses emotional, behavioral, and mental health challenges supported by the provider's master’s degree in psychology. This service also includes an equine specialist as part of the team.

Equine Assisted Counseling involves therapeutic interventions to address emotional, behavioral, and mental health challenges, utilizing the provider’s licensure in social work and school counseling. This service also includes an equine specialist as part of the team.

All services incorporate trauma-informed care to ensure emotional safety and sensitivity to client needs. Please evaluate the client’s goals and select the service area that aligns best with their requirements. For further clarification, feel free to reach out.

Choose the Equine Assisted Service that best fits the client's needs based on the information above. (ONLY for Equine Assisted Services)

Equine Assisted LearningEquine Assisted CoachingEquine Assisted CounselingWhichever option available

Strides Interventions*

Skill Development (select 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 RecoveryIndividual Skills Development and EnhancementIndividual and/or Family Psychoeducation

Indicate specific provider (if applicable)

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Strides Equestrian Therapeutic Center Referral Form

Professional Referring

Client Information

Billing Agency