Referral
Completing this form initiates your interest in Equine Assisted Services with Flying Changes. After completing this form, you will be contacted within 5 business days with next steps and program details. Feel free to call us at 540-239-8656 with any questions during the completion of this form. One form can be used for referrals within the same family unit; otherwise, individual referrals are needed.
Date completed:
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Month
-
Day
Year
Date
Name of individual(s) interested in receiving Equine Assisted Services:
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First Name
Last Name
Name
First Name
Last Name
Name
First Name
Last Name
Flying Changes only offers unmounted activities with horses, known as EAS or Equine Assisted Services. EAS can be provided in several formats with individuals, couples, families, and organizations or groups. What formats are you interested in receiving EAS? (individual, couples, families, org/groups- list all that apply)
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If you are interested in individual EAS, please provide client age(s).
What would the client(s) hope to accomplish through Equine Assisted Services?
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Please share any other helpful information in matching the client(s) with the best therapist team, such as diagnosis, preferences or specific needs/interests.
What, if any, supportive services are you/participant currently receiving? Would EAS be in addition to these services or replacing any of them?
Please share any schedule preferences such as mornings, after school or certain days of the week along with specific days as needed.
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Payment can be made through private pay or insurance, please indicate your payment plan. If intending to utilize insurance, please provide the name of your insurance.
Referral source
Referral completed by:
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First Name
Last Name
Connection to client (parent, case worker, agency, etc.)
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Preferred method of contact
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Please Select
Phone call
Text
Email
E-mail
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example@example.com
Contact Phone Number
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Referral Signature
Continue
Continue
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