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Application for Equine-Assisted Services

Applicant's Info

Birthday
Month
Day
Year
Phone (cont)
Cell
Home
Work
Preferred Contact Method
Email
Phone
Text
Multi-line address

Emergency Contact Info

Phone (cont)
Cell
Home
Work

Elegibilty Criteria

Select all that apply

I am a service member of the following:

Application Details

How did you hear about H&H?

If yes, please list the activity/program and the year you attended

If yes, please list the name and/or agency that referred you

Which Equine-Assisted Service are you applying for?
Individual Equine-Assisted Psychotherapy
Couple's Equine-Assisted Psychotherapy
Family Equine-Assisted Psychotherapy
EquiLateral - Equine Assisted EMDR

Please note: We do our best to pair you with a counselor that is available on the day(s) and time(s) you select.

Are you currently seeing a mental health provider?
Yes, currently
Not currently, but yes within last 6 months
Not currently, but yes within last 12 months
Not currently, but yes longer than 12 months ago
No, never

Equine-Assisted Services Agreements

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