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Equine Assisted Therapy

THANK YOU FOR YOUR INTEREST IN EAT.

UNFORTUNATELY WE ARE NOT CURRENTLY OFFERING THIS SERVICE.

PLEASE SEE OUR EQUINE ASSISTED LEARNING AND WELLNESS PROGRAMS.

Name of Student

First Name

Last Name

Client

Who is seeking counseling

Minor

Adult

Family

Birthday if Minor

(mm/dd/yyyy)

Name of Parent/Guardian

First Name

Last Name

Private Therapy Sessions

You will be contacted to set up a date and time.

Family Therapy Sessions

You will be contacted to set up a date and time.

List any physical limitations we need to be aware of for working with horses.

Clinical Therapy

Please let us know your therapy history.

Currently Under Treatment

Previously Under Treatment

Never had Therapy

In School Therapy

Referral

Referrals are not required unless your insurance carrier requires it for services.

Referred by current mental health professional

Referred by medical doctor

Referred by school counselor

Contact Information for Referring

Please provide name, phone number, and email of person making referral.

Contact Information of Participant

Verify Email

Phone

Address

Address Line 1

Address Line 2

City

State

State/Province

ZIP/Postal Code

PAYMENT OPTIONS

Please note HoofPrints is not a provider.

Payment Option

Bill My Insurance Provider

Self Pay, Provide Super Bill

Self Pay

OH Rise Program

INSURANCE INFORMATION

Please contact your insurance plan to confirm Jennifer Walter, LISW-S is in your network. HoofPrints will NOT be listed as a provider. You will be responsible for any fees not covered. An Equine Fee may be assessed.

Insurance Carrier Name

Phone Number for Provider

Often on the back of the card.

ID #

Group #

Insurance Card

Please attach image of front and back of Insurance Card.