HALT Foundation: Client Referral Scholarship Application Final

HALT Foundation: Client Referral Scholarship

Client Referral Scholarships provide partial funding to help individuals access Equine-Assisted Services (EAS), including equine-assisted therapy and related programs. Funding is intended to supplement other sources of support and assist clients who face financial barriers to ongoing participation. Applicants must be referred by a licensed mental health or medical practitioner. Priority is given to applicants in Virginia and to requests that expand access to EAS and strengthen mental health and wellness outcomes. Typical awards range from $300–$1,000. Applications are reviewed on a rolling basis by the HALT Foundation Scholarship Committee; please allow 2–4 weeks for review. The HALT Foundation is an equal opportunity organization and does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, or any other protected status.
Client referral scholarships support individuals referred by licensed or qualified practitioners for Equine-Assisted Services based on presenting clinical, developmental, or psychosocial needs. A formal diagnosis is not required. Referring professionals should follow the HHS HIPAA Privacy Rule.
APPLICANT / PROVIDER INFORMATION
Applicant/Provider Name

First NameLast Name
Email
example@example.com
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
List License(s), Certification(s), Professional Association Affiliation(s)
Professional Background: Please provide a summary of your education, relevant professional experience(s), current therapeutic practice and general client population you serve.
Professional Background
Years of Experience in practice, EAS or relevant field
Location of Professional Services (if different from above)
Licensed practitioner overseeing services to be provided to client referral (name & credentials if different from above)
Type of EAS or other therapeutic services to be offered
Please describe the presenting needs of the client(s) or population being referred according to/consistent with HIPPA guidelines.
Eligible presenting needs may include, but are not limited to: Mental and emotional health challenges (e.g., anxiety, depression, trauma, grief, emotional regulation); physical, developmental, or neurological differences (e.g., sensory processing, motor coordination, developmental disabilities); significant life stressors (e.g., abuse history, housing instability, caregiver burnout, military/veteran stress, family systems stress); situational or relational challenges impacting wellbeing; substance use recovery support when clinically appropriate for EAS participation.
Please share how this scholarship request will support one or more of the following: 1) increased access to EAS for clients or populations; 2) strengthening your service delivery capacity 3) broader impact on community wellbeing or the EAS field. If applicable, briefly explain financial barriers to participation or service delivery.
Cost per session or service package
Estimated number of sessions
Total Cost of Services
Requested HALT Foundation Scholarship Amount
Tentative start date of services

MonthDayYear
Date
Practitioner Referral Confirmation
How did you hear about the HALT Foundation?
Referring practitioner or organization:
ACKNOWLEDGMENTS
By submitting this application with your signature, you agree that: All information provided is accurate to the best of your knowledge Funds will be used solely for the purpose approved by the HALT Foundation You may be asked to provide proof of completion, a brief reflection, or program feedback
YOUR SIGNATURE
Date

MonthDayYear
Date
If you have questions or trouble submitting your application, please contact:
The HALT Foundation at thehaltfoundation@gmail.com
6750 Green Hill Road, Linville, VA 22834, 540-578-4301
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HALT Foundation: Client Referral Scholarship

APPLICANT / PROVIDER INFORMATION