SGR Individual/Family Application
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  • 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?*
  • Application Date*
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  • Date of Birth*
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  • Gender*
  • Pronouns
  • Format: (000) 000-0000.
  • Is the applicant a minor (under 18 years old) or dependent adult?*

  • 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 Date of Birth
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  • Additional Parent/Guardian Date of Birth
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  • Does the applicant live:

  • 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.

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  • Date of Birth
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  • Date of Birth
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  • Date of Birth
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  • Date of Birth
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  • Date of Birth
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  • Date of Birth
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  • Does the applicant or any family members carry an EpiPen?*
  • Does the applicant or any family members carry an inhaler?*

  • Applicant History

    In this section we will ask you a series of questions about the applicant/primary participant. Please be as detailed as possible in your answers. This information will help us tailor your sessions to provide the best therapeutic experience.
  • Has the applicant ever been diagnosed with a neuropsychiatric or other condition?*
  • Has the applicant ever been evaluated for a neuropsychiatric or related condition which was NOT diagnosed?*
  • Do any of the following apply to the applicant?*
  • Does the applicant have age-appropriate safety awareness?*
  • Does the applicant have any history of aggressive or violent behaviors toward self or others?*

  • Please be honest - aggressive behaviors do not automatically disqualify you. We need to know in advance so that we can ensure safety and provide appropriate support.

  • Does the applicant stim or have obsessive/compulsive behaviors?*

  • Examples of stimming (repetitive behaviors used to self-regulate): rocking, tapping, spinning, hand-flapping, vocalizing, repeating words and phrases, throat clearing, twirling hair. Examples of compulsive behaviors: cleaning, checking, counting, ordering, nail-biting, hair-pulling, binge eating, substance misuse/abuse or addiction.

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  • Does the applicant need physical assistance to sit, stand, or walk, or do they utilize any mobility devices?*
  • Does the applicant use any alternative or specialized forms of communication (AAC device, PECS, ASL, gestures, etc.)?*
  • Is the applicant currently participating in any therapies?*
  • Has the applicant ever participated in a therapeutic riding program, hippotherapy, or equine/animal assisted therapy?*
  • Has the applicant participated in any other form of therapy at any point in his/her life?*
  • Have any other family members participated in therapy at any point?*

  • Activities & Interests

    Please answer the following questions about the applicant’s favorite topics, items, characters, movies, songs, colors, etc. We incorporate these favorite things into our sessions to encourage engagement and fun!
  • Please check which (if any) of the following the applicant likes to play with/do:*

  • Education

    Please complete this section for the applicant/primary participant if they are enrolled in school or daycare.
  • Is the applicant enrolled in school (public school, homeschool, daycare, etc.)?*
  • What type of school is your child enrolled in?*
  • Is your child learning age/grade appropriate material?*
  • Does your child have an IEP or 504 plan?*

  • If YES, please include copy with application.

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  • Employment

    Please complete this section for the applicant/primary participant if they are employed.
  • Is the applicant currently employed?*

  • Veteran Status

    Please complete this section for the applicant/primary participant OR for a child applicant's parent if they identify as a veteran or have ever served as a member of the U.S. Armed Forces, Reserves, or National Guard.
  • Has the applicant ever served as a member of the U.S. Armed Forces, Reserves, or National Guard? (For children, has their parent/guardian ever served as a member of the U.S. Armed Forces, Reserves, or National Guard?)*
  • Has the applicant ever served on active duty as a member of the U.S. Armed Forces or National Guard? (For children, has their parent/guardian ever served on active duty as a member of the U.S. Armed Forces or National Guard?)*
  • In which branch(es) did the applicant serve?*
  • Did the applicant ever serve in a combat or war zone?*

  • The following information helps us better serve our military/veteran community and your answers do not affect eligibility for services at SGR.

  • Is the applicant a Disabled Veteran?*
  • Does the applicant receive VA benefits?*

  • Goals & Expectations

  • What SGR program location(s) are you interested in?
  • What type(s) of programs are you interested in?
  • Which of the following best describe the applicant's goals?*

  • Demographic Questionnaire

    In order to best serve our community and to fulfill requirements for grants, we ask you to provide certain demographic information for your household. All answers are confidential, and any data use is anonymous. The questions in this section are not considered in your application for services at SGR. Thank you in advance.
  • How did you hear about Smiling Goat Ranch or the Horse Boy Method?*
  • Do any of the following apply to your family?*
  • Language(s) spoken in the home:*
  • Do you rent or own your home?*
  • Does any member of your household have income from sources other than salary?*
  • Did any member of your household receive social security benefits or disability income in the last year?*
  • Are all members of your household currently covered by some form of health insurance or health plan?*
  • Which of the following best describes your marital/family status?*
  • Which of the following best describes your race/ethnicity?*

  • 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?

  • 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.

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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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