Returning Client

Trotting Horse Therapeutic Riding (THTR)

Returning Client Form
Client Information
Name*
Age*
Height*
Weight (Please note we offer both riding and non-riding options. For riding, we have a weight limit of 220 lbs due to the size and age of our horses.)*
Legally Responsible Party for Client and Billing:
Name*
Relationship to Client*
Cell Phone*
Email
example@example.com
Texting OK?*

YesNo
Mailing Address
Do you give permission to use image (photo) of client in social media and advertising promoting THTR?

YesNo
Will you be paying with Medicaid?

YesNo

Individuals paying with Medicaid
Caseworker Name
Caseworker Phone
Caseworker Email
example@example.com
I give THTR and/or Back Office Solutions permission to contact this caseworker for billing purposes

YesNo
*Note: THTR is covered under Montana Medicaid Community & Home Based Services. Your caseworker MUST provide us with a Prior Authorization Referral. ANY and ALL charges not covered by Medicaid will be billed and due by the client or guardian.

EMERGENCY CONTACT INFORMATION - REQUIRED for ALL

Please furnish the name and phone # of a contact person (if under 18, in addition to parent)
Name*
Relationship to Rider*
Home Phone
Cell Phone*
Work Phone
Address
Physician Name
Physician Phone
If any of the following has changed since we last saw you, please provide THTR with updated version:

Current Medication List * Allergies * IEP * Physical Restrictions

Upload file below, email us a PDF, or bring us a physical copy.
File Upload

Cancelof
What are client's or guardian's goals for this session?*
Availability: Pick one or both sessions, and list any periods of time available each day (eg 3:45-5; Anytime after 4pm, etc)

Session 1Session 2
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Top Choice (we'll do our best!)
Should be Empty:

Trotting Horse Therapeutic Riding (THTR)