1-877-HORSE10 info@hhhusa.org

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 Marlena@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 :
    MaleFemale

    Birth Date :

    Age :

    Address :

    Home Phone :

    May we leave a message?
    YesNo

    Cell Phone :

    May we leave a message?
    YesNo

    E-mail :

    PARENT/GUARDIAN INFORMATION

    Name of Parent/Legal Guardian :

    Home Phone :

    May we leave a message?
    YesNo

    Work Phone :

    May we leave a message?
    YesNo

    E-mail :

    Relationship :
    Never MarriedMarriedSeparatedDivorcedParent 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?
    YesNo

    Current or Prior :

    If prior, why did you discontinue/stop?

    With whom?

    Diagnosis?

    Is child currently receiving psychiatric services or professional counseling
    elsewhere?
    YesNo

    With whom?

    How is child’s current physical health?
    PoorUnsatisfactorysatisfactoryGoodVery 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?
    FrequentlySometimesRarelyNever

    Has child engaged in recreational drug use?
    FrequentlySometimesRarelyNever

    Has anyone ever been concerned about child's drug/alcohol use?
    YesNo

    Has anyone very pressured child into drug/alcohol use?
    YesNo

    Has child had suicidal thoughts recently or in the past or ever attempted suicide?
    YesNo

    If yes, please explain?

    When?

    Is child having thoughts of harming others or self?
    YesNo

    Has child experienced physical abuse?
    YesNo

    Has child experienced emotional abuse?
    YesNo

    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:

    YesNo  
    Extreme Depressed Moods?

    YesNo  
    Wild Mood Swings?

    YesNo  
    Rapid Speech?

    YesNo  
    Extreme Anxiety?

    YesNo  
    Panic Attacks?

    YesNo  
    Phobias?

    YesNo  
    Sleep Disturbances?

    YesNo  
    Hallucinations?

    YesNo  
    Unexplained Losses of Time?

    YesNo  
    Unexplained Memory Lapses?

    YesNo  
    Alcohol/Substance Abuse?

    YesNo  
    Frequent Body Complaints?

    YesNo  
    Eating Disorder?

    YesNo  
    Body Image Problems?

    YesNo  
    Repetitive Thoughts (e.g. obsessions)?

    YesNo  
    Repetitive Behaviors (frequent checking, hand washings, etc.)?

    YesNo  
    Homicidal Thoughts?

    YesNo  
    Suicide Attempt?

    YesNo  
    Self Harm?

    FAMILY’S MENTAL HISTORY

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

    YesNo  
    Difficult Family Member?

    YesNo  
    Depression?

    YesNo  
    Bipolar Disorder?

    YesNo  
    Anxiety Disorders?

    YesNo  
    Panic Attacks?

    YesNo  
    Schizophrenia?

    YesNo  
    Alcohol/Substance Abuse?

    YesNo  
    Eating Disorders?

    YesNo  
    Learning Disabilities?

    YesNo  
    Trauma History?

    YesNo  
    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 :  
    YesNo

    Saturdays, 11:45am to 1:45pm for elementary school and middle school ages :  
    YesNo

    Saturdays, 2:00pm to 4:00pm for middle and high school ages :  
    YesNo

    2)   RSVP (SignUp.com)

    RSVP (SignUp.com)
    You will receive an email regarding session times and you will need to respond to the email to effectively RSVP for the session. RSVP is required so that we can confirm that there is enough, volunteers, trainers and horses. If you do not RSVP, there is a chance that your child will not be able to ride for that day. If you need to cancel the child’s attendance for a session for any reason, please notify us via phone at 877-467-7310 or info@hhhusa.org, 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 such 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 :

    Please allow 2 to 4 days for our administrative offices to review your application.

    If your child is an eligible candidate for our programs, an office representative will call or email you within five days to schedule an in person meeting at a later date to review the application in more detail.

    For any further questions please contact info@hhhusa.org
    or call 1-877 HORSE 10  

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