Harmony Horsemanship, Confidential Referral

HARMONY HORSEMANSHIP
Confidential Referral
We ask that referrers complete this referral form from their own observations rather than the participant's perspective.

We will be asking for similar follow up information on all participants 2-months post course. Please do not refer unless you are willing to participate in this as it's vital for our ongoing research supervised by Bournemouth University located in Poole, England. Thank you!
Date

MonthDayYear
Date
Participant Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Gender
Pronouns
School
Residential Facility (if applicable)
Participant Zip Code
Contact details for participant (over 18) or parent/guardian (under 18):
Name (if different than participant)
Relationship to Participant (if under 18)
Phone
Format: (000) 000-0000.
Email
example@example.com
Contact details to arrange booking if different to above
Name:
Relationship to participant:
Phone:
Format: (000) 000-0000.
Email:
example@example.com

Referrer Information:
Referrer's Name

PrefixFirst NameLast NameSuffix
Referrer's Organization
Referrer' Phone
Please enter a valid phone number.Format: (000) 000-0000.
Referrer's Email
example@example.com
HIPPA: do you have consent or other lawful basis to share this person's data?
Can we stay in touch with referrer for evaluation/research purposes?

Referral Information on participant:
Mental Health diagnosis? Other diagnosis?
What talk-based support or other provisions have been offered?
Our service is for people for whom talking is not working. Please could you describe the problem? ex: disengaged / non-responsive / "stuck"
Are other agencies involved? Ex, VA, DCFS, etc. If so, who?
Is it appropriate for the participant to work one on one?
Risks we should know about? (re: safeguarding the participant or re our own safety):

Please consider the THC Star included below and rate the candidate's current levels according to your own impressions. Star Scores: From 0=Stuck to 4=Competent, in 8 areas (see key on included Star.)

Rows	Star Rating
Assertiveness
Focus & Perseverance
Taking Responsibility/ Agency
Relating to Others / Empathy
Calmness
Realistic Planning/ Analysis
Communication & Language
Engagement/ Confidence as a Learner

Please comment on the following areas for the participant:
Poor engagement with Treatment/Education/Training/Work?
Problem Behaviors (e.g. drug, alcohol, offending, mental health diagnoses, homelessness, eating disorders, disruptive, bullying, isolated...):
Problems with Relationships? (family, peers, professionals)
Identity (e.g. low self esteem, poor self image, lacks hope, ambition, self belief):
Any specific outcomes you hope for as the referrer?

Other Information:
How is this course being funded? (Please give contact details for invoicing, or discuss charitable funding options with us)
Has Participant or Parent/ Guardian completed a consent form?
Has Participant or Parent/ Guardian completed a liability waiver?
Normally participants are transported by parents, guardians, referrers or by taxi/ Uber. If friends or family are transporting we need you to assess the risk for their suitability to have unsupervised access to our premises.
Please note:
- These farms are also the private homes of those who own them.
- Brock Farm specifically is owned and occupied by an elderly couple who may be vulnerable to predators.
- There may be other vulnerable young people on the premises, consider any safeguarding issues.
- The environment contains unsupervised horses and equipment.
- We only have skeleton staffing – we supervise participants but cannot supervise other visitors.
- Our facilities are rented/ loaned and good relations with our landlords/ neighbors is essential.
Travel arrangements to and from sessions:

Privacy Notice
Harmony Horsemanship controls data in accordance with the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Our Data Protection Policy is available on request, detailing retention periods and rectification processes.
The purpose of this form is to obtain referral information regarding the participant named and contact information for the person referring them into our service. This information will be used only for the purposes for which it is given. We will seek consent for all our data processing from the participant upon first contact.
Should be Empty:

HARMONY HORSEMANSHIP

Confidential Referral

Participant Information

Contact details for participant (over 18) or parent/guardian (under 18):

Contact details to arrange booking if different to above

Referrer Information:

Referral Information on participant:

Other Information:

Privacy Notice