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
Art Wellness
Animal Wellness
Yoga Wellness
Equine Assisted Service
Parent Coaching
Service Array
*
Wellness Management and Recovery
Individual Skills Development and Enhancement
Individual and/or Family Psychoeducation
Billing Agency
(Veterans Only)
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Submit
Should be Empty: