Referral Form

Trotting To Happiness

Referral Form

Date / Time

First Name

Last Name

DOB

Age

Height

Weight

Phone Number

Your Address

Emergency Contact Details

First Name

Last Name

Relationship

Phone Number of Emergency Contact

Any Information needed to be provided if required to emergency services

Consent- In the event emergency aid /treatment is required due to illness /injury during the process of receiving services ,or whilst being on the property of Trotting to Happiness I authorise S Kaye Weaver to – secure and retain medical treatment and transport if needed and release client records upon request to authorised individual or agency involved in medical treatment. This authorisation includes x-rays surgery, hospitalization, medication, and any treatment deemed “lifesaving” by the physician. This provision will only be invoked if the person(s) above is unable to be reached.

First Name

Last Name

Health History

Please answer all items
Have you had or do have difficulties in any of the areas below

If you have answered YES to any of the above, please provide details here along with any other information you feel is relevant.

Please advise any prescribed medication currently being taken.

Goals and Objectives

What are your reasons for seeking support from trotting To Happiness - Equine Assisted Therapy

What are your goals?

Do you have any specific learning style? (please select from the dropdown list)

Please provide any further information you feel relevant with regard to your Goals and Objectives

Current Social Circumstances

Please provide as much detail as possible for each of the following topics

School/Education/Employment/Occupation?

Who do you currently live with?

Current hobbies/interests?

Support networks

Professional agencies

Fee Agreement

Trotting to Happiness endeavours to keep the fees as low as possible for anyone taking part in this service while maintaining the optimum health of the horses and maintenance of the facility.

The prices for session are currently

£60 per hour
10% discount for NHS staff, social care staff, Military and ex-military staff with valid evidence.

This must be paid either by Cash on the day or Bacs transfer within 24 hours.

Session format will be set by Trotting to Happiness at the time of initial assessment with discussion with Client.

Following first session there will be a discussion around whether both parties will continue and if it is felt to be appropriate then there is an expectation the client will attend a further 4 sessions. Following the fourth session the client can choose whether to continue or end the sessions.

Cancellations must be done with plenty of notice any cancellations done within 24 hours full payment will be required.

If there is a cancellation due to adverse weather conditions determined by Trotting to Happiness or due to unforeseen emergency medical issues then no fee will be applied. These terms will remain in effect until the individual completes their time at Trotting to Happiness.

PLEASE PROVIDE CONSENT

Please tick this box to provide consent for a member of our team to contact you with regard to this form submission. Please also take a moment to read our privacy policy with regard to how we handle your data.