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 and/or Age*

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.

Whichever Equine Assisted Service is Available

Wellness Management and RecoveryIndividual Skill Development and EnhancementCounseling & Therapeutic Services (CLTS Holly or Lisa)

Equine Assisted Coaching with Priscilla or Holly (MS)

Wellness Management and RecoveryIndividual Skill Development and EnhancementCounseling & Therapeutic Services (CLTS-Holly Only)

Equine Assisted Counseling with Lisa (MS)

Wellness Management and RecoveryIndividual Skill Development and EnhancementCounseling & Therapeutic Services (CLTS ONLY)

Equine Assisted Learning with an Equine Specialist ONLY

Individual Skill Development and EnhancementOther

Art Wellness with Kat or Justin

Wellness Management and RecoveryIndividual Skill Development and EnhancementCounseling & Therapeutic Services (CLTS ONLY)

Yoga Wellness with Jolyn

Wellness Management and RecoveryIndividual Skill Development and Enhancement

Parent Coaching

Wellness Management and RecoveryIndividual Skill Development and EnhancementPsychoeducation

Skill Development (Mentoring)

Individual Skill Development and Enhancement

Indicate specific provider (if applicable)

Trauma & Teens Support Group

Interested

Transgender Support Group

Interested

Service Array

Individual Skill Development and EnhancmentOther

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Strides Equestrian Therapeutic Center Referral Form

Professional Referring

Client Information

StrideRise Support Groups

Billing Agency