RANCH COUNSELING WELCOME FORM

YOUR WELLNESS JOURNEY STARTS HERE!

Welcome to the Ranch!
Thank you for your interest in Bit of Hope Ranch's Wellness Programs. I have received your request for therapy information and would like to help you start your healing journey. Please submit the following and our team will be in touch with insurance information and a start date for services.

Our services are offered for clients ages 5 and up.

Linda Paquette

Client Communication Specialist
lindapaquette@bitofhoperanch.org
Date*

MonthDayYear
CLIENT'S NAME

Client First NameClient Last Name
CLIENT'S DATE OF BIRTH

MonthDayYear
NAME OF PARENT/GUARDIAN

Guardian First NameGuardian Last Name
Phone Number*
Please enter a valid phone number.
E-mail*
MENTAL HEALTH WELLNESS PROGRAMS
Please choose from the following:

Equine Assisted Psychotherapy (EAP) is facilitated by a licensed counselor and includes an equine professional and horse(s). Ground based (non riding) and a trauma based riding module are utilized in sessions. You and your counselor will decide the best treatment plan for you after your intake/initial session. Contact us to verify your insurance benefits. Self Pay is $135/session. Initial Intake Session is $160.Walk and Talk/ Somatic Therapy is facilitated by a licensed counselor. These sessions can explore the walking trails, the Barnyard, the waterfront dock or and the 50' Jump Pillow. Contact us to verify your insurance benefits. Self Pay is $110/session.Traditional/CBT Therapy is offered in the private indoor or outdoor spaces. A licensed therapist will facilitate the session. Contact us to verify your insurance benefits. Self Pay is $110/sessionEquine Assisted Coaching offers ground and riding modules for clients that are "stuck", going through life transitions or just needing some self care time. These are led by a trained facilitator and a horse. Self Pay is $125, no insurance can be billed for these services. Non-equine Coaching services are also offered at this rate.The Mace Energy Method and the Emotion Code sessions are offered onsite or via zoom. These sessions address hidden issues that are the cause of emotional and physical issues. Both of these are non-disclosure so no sharing embarrassing details. These can be used anytime during your counseling journey. These are self pay at $50-$250/ session.DISCOVERY CALL: A free 15 minute call to answer your questions about one of the above checked programs.
INSURANCE VERIFICATION

We offer insurance filing as a free service for clients. Clients are responsible for any amount that insurance does not cover. Please note that Coaching and Mace/Emotion Code services are self pay only.
We accept some insurances such as Partners Behavioral Health Medicaid, AmeriHealth, Carolina Complete, Healthy Blue, BCBS, Aetna, UHC and Cigna. If you do not have insurance or are out-of-network, we also offer self-pay services.
INSURANCE NAME
INSURANCE GROUP/ ID NUMBER
FRONT OF CARD PHOTO
BACK OF CARD PHOTO
Upload a picture of the card if you cannot access your camera

Cancelof
PRIMARY CARE PHYSICIAN AND NUMBER
SCHEDULING INFORMATION
Our team will reach out about available dates for a therapist. You will be asked to create a Simple Practice account that will manage your schedule, reminders, payment info, etc.

Please select your time options below. Please note that longer wait times can be for after 3:00 p.m.
I would like an appointment for:

Mornings 9-12Afternoons 12-3After school 3-7After work: 5-7
WHAT COUNSELOR IS RIGHT FOR YOU?

Help us find the perfect counselor for you by answering the following questions.
Why are you seeking therapy services?
Have you ever been in counseling for this before? If so, When and for how long?
Do you have a doctor or psychiatrist you see for the above said struggles?
Do you have a preference of male or female therapists and if so what is your preference and why?
Please share any other helpful information or request your preferred counselor.
YOUR FIRST VISIT

We are ready to meet you!
PARKING:

Please drive SLOWLY down the driveway as we have traffic coming and going. Park behind the RED BARN and come in the end of the barn or through the office entrance to the waiting area. Do not leave your car running as we value the clean air in and around the barn.

WAITING AREA:

Please wait for your counselor in the waiting area inside of the barn. There are drinks for sale in the kitchen. Bathrooms are located outside in the main parking lot. There is a playground for siblings by the waterfront. No outside pets please. Also, there is no smoking or vaping on the grounds.

ATTIRE:

Dress for the weather! Layers work best to stay comfortable in the winter. CLOSED TOED SHOES are required. No crocks or sandals. Tennis shoes and boots are the safest around the horses and grounds.

PAYMENT

Payment and copays are due at the time of service. A credit card on file will be used for payment. We also accept cash or check.
GET MORE INVOLVED AT THE RANCH

PLEASE CONTACT ME ABOUT THESE OTHER GREAT PROGRAMS
THERAPEUTIC RIDING LESSONS FOR SPECIAL NEEDS/SPECTRUM DISORDERSRIDING LESSONS: PRIVATE OR SADDLE CLUBCORPORATE COACHING FOR LEADERS/GROUPSBIRTHDAY CELEBRATION RENTALSWEDDINGSCORPORATE VENUE RENTALVOLUNTEERINGBOARD AND EVENT PLANNINGDONATING/HORSE SPONSORSHIPS
Should be Empty:

YOUR WELLNESS JOURNEY STARTS HERE!

MENTAL HEALTH WELLNESS PROGRAMS

INSURANCE VERIFICATION

SCHEDULING INFORMATION

WHAT COUNSELOR IS RIGHT FOR YOU?

YOUR FIRST VISIT

GET MORE INVOLVED AT THE RANCH