Participant Application

Dear Parent / Guardian:

Thank you for your interest in Horses Healing Hearts. HHH is a 501c3 organization that is dedicated to helping children of alcoholics and addicts build self-esteem and confidence by working with horses. In addition to our
curriculum-based support groups we use the horses as a vehicle to teach children
empathy, trust, boundaries, and responsibility. Our goal is to end the
generational cycle of addiction. Please note HHH is NOT therapy.

Please complete the information below and return to Sharon Smith at
sharon@hhhusa.org. Upon review of the attached information, we will contact
you regarding the next step in your child becoming a participant in Horses Healing
Hearts.

TUITION INFORMATION

HHH works to keep our program fees as low as possible.

Our session expense for each child is $80.00; however, a portion of this amount is
subsidized through support of our generous donors. Consequently, we are able
to offer a sliding fee scale so every child has the opportunity to take advantage of
our services. No child is turned away due to financial reasons. In order to
maintain minimal administrative expenses, each parent/guardian is required to
pay their child’s fees by registering for the automated monthly payment system
through pay pal.

Financial assistance may be available to those who qualify. To apply for financial
assistance, please provide either 2 pay stubs or a tax return. If unemployed,
please provide proof of state or county assistance.

Monthly Amount* Household Income
$40 Under $25,000
$20 Each additional child at half price
$60 $25,000 – $34,999
$30 Each additional child at half price
$100 $35,000 – $49,999
$50 Each additional child at half price
$120 $45,000 – $54,999
$60 Each additional child at half price
$140 $55,000 – $64,999
$70 Each additional child at half price
$160 $65,000 and up
$80 Each additional child at half price

*There are no refunds for missed sessions

INTAKE FORM

Please provide the following information for our records. The information you
provide here is held to the highest standards of confidentiality.

Name :

Date :

Gender :
 Male Female

Birth Date :

Age :

Address :

Home Phone :

May we leave a message?
 Yes No

Cell Phone :

May we leave a message?
 Yes No

E-mail :

PARENT/GUARDIAN INFORMATION

Name of Parent/Legal Guardian :

Home Phone :

May we leave a message?
 Yes No

Work Phone :

May we leave a message?
 Yes No

E-mail :

Relationship :
 Never Married Married Separated Divorced Parent Deceased

With whom does the child reside?

Please provide a brief explanation of any custody or visitation arrangements :

What role does each parent play (time spent with child, regular visit days)?

YOUTH HEALTH AND SOCIAL INFORMATION :

Issues of concern today :

Is child in counseling?
 Yes No

Current or Prior :

If prior, why did you discontinue/stop?

With whom?

Diagnosis?

Is child currently receiving psychiatric services or professional counseling
elsewhere?
 Yes No

With whom?

How is child’s current physical health?
 Poor Unsatisfactory satisfactory Good Very good

List any past/present physical symptoms or health concerns of child (e.g. pains,
headaches, earaches, diabetes, etc.) :

History of child hospitalization or surgery :

History of child concussions :

What medication(s) is child presently on?

Has child engaged in alcohol use?
 Frequently Sometimes Rarely Never

Has child engaged in recreational drug use?
 Frequently Sometimes Rarely Never

Has anyone ever been concerned about child's drug/alcohol use?
 Yes No

Has anyone very pressured child into drug/alcohol use?
 Yes No

Has child had suicidal thoughts recently or in the past or ever attempted suicide?
 Yes No

If yes, please explain?

When?

Is child having thoughts of harming others or self?
 Yes No

Has child experienced physical abuse?
 Yes No

Has child experienced emotional abuse?
 Yes No

What school does child attend?

Grade :

Child's favorite subject in school?

Child's good friends?

What do you consider to be child’s strength?

YOUTH’S MENTAL HEALTH HISTORY :

In the last year, what significant life changes or stressors has child experienced?

Has child ever experienced:

 Yes No  
Extreme Depressed Moods?

 Yes No  
Wild Mood Swings?

 Yes No  
Rapid Speech?

 Yes No  
Extreme Anxiety?

 Yes No  
Panic Attacks?

 Yes No  
Phobias?

 Yes No  
Sleep Disturbances?

 Yes No  
Hallucinations?

 Yes No  
Unexplained Losses of Time?

 Yes No  
Unexplained Memory Lapses?

 Yes No  
Alcohol/Substance Abuse?

 Yes No  
Frequent Body Complaints?

 Yes No  
Eating Disorder?

 Yes No  
Body Image Problems?

 Yes No  
Repetitive Thoughts (e.g. obsessions)?

 Yes No  
Repetitive Behaviors (frequent checking, hand washings, etc.)?

 Yes No  
Homicidal Thoughts?

 Yes No  
Suicide Attempt?

 Yes No  
Self Harm?

FAMILY’S MENTAL HISTORY

Have immediate family members or relatives experienced difficulties with the
following? If yes, please list relationship :

 Yes No  
Difficult Family Member?

 Yes No  
Depression?

 Yes No  
Bipolar Disorder?

 Yes No  
Anxiety Disorders?

 Yes No  
Panic Attacks?

 Yes No  
Schizophrenia?

 Yes No  
Alcohol/Substance Abuse?

 Yes No  
Eating Disorders?

 Yes No  
Learning Disabilities?

 Yes No  
Trauma History?

 Yes No  
Suicide Attempts?

RELIGIOUS/SPIRITUAL INFORMATION

What is your family's religious/faith preference?

PROGRAM SUCCESS PLAN

Issues :

Goals :

Potential Obstacles :

This is Computer generated Form and does not need Signature or stamp

PREVENTION SUPPORT GROUP AGREEMENT

This agreement is designed to help build a positive working relationship between
you, your child, and HHH. It also informs you of you and your child’s rights and
responsibilities within our organization. If you have questions or concerns, please
feel free to discuss them with HHH.

1)   SESSION SCHEDULE:

For scheduling please check one of the following:

Wednesdays, 4:30pm to 6:30pm for all ages :  
 Yes No

Saturdays, 11:30am to 1:30pm for elementary school ages :  
 Yes No

Saturdays, 11:30am to 1:30pm for middle and high school ages :  
 Yes No

Saturdays, 2:00pm to 4:00pm for middle and high school ages :  
 Yes No

2)   RSVP (SignUp.com)

RSVP (SignUp.com)
If you need to cancel child’s attendance for a session for any reason, please
notify us via phone at (561) 305-9055 or sharon@hhhusa.org or through
SignUp.com, at least 24 hours in advance.

3)   GROUP RULES

  • One person talks at a time
  • Respect each other
  • You can pass
  • Put ups only
  • What we say here stays here

4)  CONFIDENTIALITY

Although we are a prevention program and not a therapy service, we are
mandated by the state of Florida to report any child’s sharing of the
following:

  • Threats of suicide
  • Threats of self-harming
  • Incident of harming another person

Due to fact the child is our client, we are committed to maintaining
confidentiality with any information they share, with the exception of the
three points above.

HHH RELEASE

RELEASE AND HOLD HARMLESS AGREEMENT

The undersigned participant and/or parent or legal guardian, acknowledges that
there are inherent risks involved in riding and working around horses. Those risks
include injury, personal property damage, and death, and the risks arise from
using, riding, or being in close proximity to horses. The undersigned participant
also acknowledges that both horse and rider can be injured in normal use or in
competition and schooling.

With full understanding of the risks stated in the above paragraph, the
undersigned participant does hereby release and hold harmless the following
listed entities from any and all claims, including claims of either active or passive
negligence
, related to or arising from the undersigned participant’s interactions
with the following listed entities: Horses Healing Hearts, Inc. and it’s Board of
Directors, Officers, Committees, Assignees, volunteers, stated or implied agents
(either individually or in their corporate capacity) heirs, successors, assigns,
executors, and legal representative. The undersigned participant and or parent or
legal guardian, further agrees to indemnify the above-listed entities for all costs,
losses, damages, and expenses, including court costs and reasonable attorneys’fees, suffered by any of the above-listed entities arising out of any and all claims,
including claims of either active or passive negligence, brought in relation to the
undersigned participant’s interactions with the above-listed entities.

I DO EXPRESSLY CONSENT TO ASSUME THE RISK OF ANY CHANGE OF HARM,
INJURY, DEATH, PERSONAL DAMAGE, REAL PROPERTY DAMGE, OR SUFFERING,
ARISING FROM OR IN THE COURSE OF MY, OR SAID MINOR’S PRESENCE ON THE
PREMISES OF ANY HHH SPONSOR BARN PROPERTY.

The following statement is made in accordance with Florida Statute 773.04:

Under Florida Law, an equine sponsor or equine professional is not liable for an
injury to, or death of, a participant in equine activities resulting from the
inherent risks of equine activities

Additionally, Horses Healing Hearts’ employees, volunteers, contractors, and
agents all fully comply with Florida Statute 39.201, which requires that any
person who knows, or who has reasonable cause to suspect, that a child is
intending to harm his/herself or others, is abused by an adult other than a parent,
legal custodian, caregiver, or other person responsible for the child’s welfare,
shall report suck knowledge or suspicion to the Florida Department of Children
and Families

I have received, read and understand the Prevention Support Group Agreement
and Notice of Privacy Rights. I authorize the release of the minimum amount
necessary of my child’s personal health information to Horses Healing Hearts,
Inc.

Parent/Legal Guardian Signature :

Date :

Parent/Legal Guardian Signature :

Date :