SGR Individual/Family Application

SGR Individual/Family Application

To begin the application process, please fill out the following form. Once our team has reviewed your application, we will contact you to schedule a consultation session. The purpose of the application and consultation are to ensure our program is a good fit for your family’s needs and goals. Please provide as much information as possible to help us fully understand the needs of your child/family and accommodate you as best we can. Our sessions are individualized, so the more detailed, honest, and accurate information we have the better job we can do. All information provided is confidential.

If applicable, please provide copies of any IEPs, 504 plans, or other evaluations/reports which can help us better understand your child’s needs and goals. Please also provide contact information for at least one reference who can give us a more well-rounded picture of you and your family. Suitable references include therapists, teachers, and other professionals who have worked with you or your family for one year or longer.

Disclaimer: We have a limited number of spots available for our programs. Completion of this application form does not guarantee you a spot in our programs. If your application is approved, you will receive twelve weekly sessions at which point we will work with you to determine whether continuing sessions would be beneficial. Please note that if you miss two or more sessions without prior arrangement, you will be charged a $25 no-show fee and may lose your spot in the program.

Smiling Goat Ranch exists to provide therapeutic services free of charge for families in need. For that reason we do not charge any families for services, and instead ask you to donate what you are able. Donations, fundraising, and grants are essential for us to care for our herd of therapy animals and provide these services for your family and others in the community. We have several levels of suggested donation which are dependent on your combined household income listed below:

Less than $25,000	full scholarship
$25,000 - $50,000	$50 per month
$50,000 - $100,000	$100 per month
$100,000 - $150,000	$250 per month
150,000 +	$400 per month

You can set up a one-time or monthly donation online at www.coloradogives.org/smilinggoatranch

Contact Information

Please provide the following information about the applicant/primary participant.
Who is completing this form?*

Applicant (myself)ParentSpouse/PartnerNon-Related CaregiverOther
Name of Applicant/Primary Participant*

First NameLast Name
Preferred Name or Nickname
(if different)
Application Date*

MonthDayYear
Date of Birth*

MonthDayYear
Date
Applicant Age*
Gender*

MaleFemaleNon-binaryOther
Pronouns

She/HerHe/HimThey/ThemOther
Height*
Weight*
Contact Phone Number*
Please provide the best phone number to contact the applicant (parent/guardian, if under 18).
Contact Email*
Please provide the best email address to contact the applicant (parent/guardian, if under 18).
Preferred Contact Method
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState

Zip Code
Is the applicant a minor (under 18 years old) or dependent adult?*

YesNo
Please note we require at least one parent, guardian, or other caregiver to attend sessions with children (under 18) or dependent adults.
Family Information

Please provide the following information about the applicant’s siblings, children, spouse, or other members of the family/household even if you do not expect them to attend programs. Please note we encourage the whole family to participate in sessions when possible.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Date of Birth

MonthDayYear
Date
Additional Parent/Guardian Name

First NameLast Name
Additional Parent/Guardian Date of Birth

MonthDayYear
Date
Parent/Guardian Phone Number(s)
Provide the phone number(s) for the applicant's parent/guardian or caregiver(s), if different from the primary contact above.
Parent/Guardian Email(s)
Provide the email address(es) for the applicant's parent/guardian or caregiver(s), if different from the primary contact above.
Does the applicant live:

IndependentlyWith familyWith a non-related caregiverGroup home/community livingOther
Additional Family Members

Please provide the name(s), relationship to participant, date of birth, and gender of the applicant's siblings, children, spouse, or other members of the family/household, if applicable.

	Full Name	Relationship	Date of Birth	Gender
1
2
3
4
5
6
7
8
9
10

Name

First NameLast Name
Relationship
Date of Birth

MonthDayYear
Gender
Name

First NameLast Name
Relationship
Date of Birth

MonthDayYear
Gender
Name

First NameLast Name
Relationship
Date of Birth

MonthDayYear
Gender
Name

First NameLast Name
Relationship
Date of Birth

MonthDayYear
Gender
Name

First NameLast Name
Relationship
Date of Birth

MonthDayYear
Gender
Name

First NameLast Name
Relationship
Date of Birth

MonthDayYear
Gender
Does the applicant or any family member have any medical conditions/allergies or take any medications?*
If YES, please explain. Be detailed and specific. We need to know of any allergies/medications in case of an emergency.
Does the applicant or any family members carry an EpiPen?*

YesNo
Does the applicant or any family members carry an inhaler?*

YesNo
Please briefly tell us about the applicant/your family and why you're applying for services at Smiling Goat Ranch.

Additional Information & Attachments

Once you submit this form, our team will review your application and contact you if any additional information is required or to schedule an on-site consultation. Please email kaylee@smilinggoatranch.com with any questions.
Individuals who have been the victim of a violent crime in Garfield, Pitkin, or Rio Blanco counties may be eligible for victim compensation including reimbursement to Smiling Goat Ranch for therapeutic services. If you answer yes below, we may ask you for additional information related to this program.

You can learn more about the 9th Judicial District Crime Victim Compensation program at https://www.9daco.org/victim-compensation/
Has the applicant or any other family member been a victim of crime?

YesNoNot SurePrefer not to answer
Please provide the name, relationship, and contact phone number or email address for at least one reference who can give us a more well-rounded picture of you and your family. Suitable references include therapists, teachers, and other professionals who have worked with you or your family for one year or longer.
References:
Upload Attachments

Please provide copies of any IEPs, 504 plans, or other evaluations/reports which can help us better understand your needs and goals.
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Smiling Goat Ranch is a 501(c)(3) nonprofit that has helped hundreds of children and adults. From day one we made a vow never to let fees hinder healing; therefore, all of our program needs — including animal feed and care, supplies, and handlers — come from donations and grants. With a $120,000 annual budget, we are incredibly grateful to those who are in a position to join us with their support. To learn more about all of the ways you can support programs at SGR visit www.smilinggoatranch.com and click Get Involved. Thank you in advance for helping us to continue our mission!
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SGR Individual/Family Application

Contact Information

Family Information

Applicant History

Activities & Interests

Education

Employment

Veteran Status

Goals & Expectations

Demographic Questionnaire

Additional Information & Attachments