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Herd By a Horse Autism Group fall 2017

This programs serves children 7-12 years old that stuggle with sensory disorder and autism challenges. Sessions are $35/session or $200 for paying for all 6 upfront. THIS SESSION IS FULL BUT PLEASE COMPLETE THE FORM BELOW FOR A WAITING LIST OPTION.

Client Information

Client Name

First Name

Last Name

Client Date of Birth

00/00/0000

Please check all that apply

My child is non verbal.

My child is non verbal but can follow verbal directions.

My child is verbal.

My child's primary language is English. Please note that we do not have an interpreter on site at this time.

Guardian Name

First Name

Last Name

Guardian Email

Verify Email

Guardian Phone

Client Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Guardian Address if different that client's

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Referred By:

Medical Consent Form Information

Each participant will need to sign a liability release form that includes a medical release form.

Physician's Fax Number

Optional Upload: Signed Liability Release Form File Upload

Use this to upload your completed liability release form

Payment Options

DO NOT PAY BEFORE THE THERAPIST CONFIRMS THAT YOU ARE IN THE GROUP. Mail or drop off cash or check to Bit of Hope Ranch 5001 CR Wood Rd Gastonia, NC 28056

Pay by check or cash

online/cc

Online Payment

$35 - one session

$200 - Full 6 weeks with discount