STAT INC EQuine Affect™ SUD Recovery: Equine Assisted Learning Program

12 WEEKLY TOPICS:

Mindset Self-Awareness Motivation Self-Regulation Social Skills Empathy Relationships Well-Being Honesty Resiliency Hope Personal Growth

12 WEEKS OF PERSONAL DEVELOPMENT ALONGSIDE HORSES

What this EQuine Affect™ IS: 12 Weekly; 2-hour Equine Assisted Learning (EAL) sessions for individuals, Men’s and Women’s small groups for people challenged with a Substance Use Disorder (SUD). EQuine Affect™ is a mostly ground based, with optional mounted exercises, Personal Development EAL program STAT Inc. has designed to support your courage and growth in recovery. It is an adjunct recovery supportive service.

You will have the opportunity to explore emotional intelligence, as you learn more about yourself through EAL sessions, which are strength based and resiliency focused. Rain or Shine, we are ready to work with you, for you. You can apply for the program scholarship while completing residential treatment or after 30 days of sobriety. *Some restrictions apply.

What this program IS NOT: an exclusive riding or horsemanship skills training, a SUD or diagnostic psychiatric evaluation, or psychotherapy processing group. Our intention is that you learn more about yourself and personal growth in recovery from horse and human team members.

Veterans: to participate in STAT's Recovery Program for Veterans made possible through the VA Adaptive Sports Grant click on the application link: Veteran Application https://hushforms.com/stat-veteran-programs

Currently, applicants can submit this application to be placed on a WAITLIST, as we await grant funding. We are hopeful to have future funding to offer this program again at no cost.

If you are interested in self-pay or are applying under an Agency, please check this box and you will be contacted for a screening interview.

Please complete the confidential and encrypted EQuine Affect™ Participant Application web form below. Upon review of the application, a screening interview phone call by a STAT Staff member will be scheduled to ensure a good fit for the grant funded program.

Privacy Policy STAT Inc will keep inform provided on this form confidential and will not share or sell your information provided on this form. Once you submit this form, it is sent to Hushmail's encrypted, secure and HIPAA compliant server. It is not maintained on Wix's website.

Yes, I understand

Program Participation Info

Program Participation Restrictions This EAL Recovery program does not provide services for individuals with criminality: history of cruelty to animals, court mandated services and/or anger management, violent offense(s), sexual offences, Megan’s Law.

I attest that I do not have the criminality restrictions listed above

This SUD EAL program is not an appropriate fit for individuals with: a serious persistent mental illness, a need for trauma focused psychotherapy, a need for outpatient psychiatric services for stabilization, recent psych inpatient hospitalization, a phobia of large animals, and medical related issues around large animals

None of these needs and conditions apply to me I am not sure about fit for the program but would still like to apply

We will clarify any questions during the screening interview. If not a good fit, we can give some mental health referral options for you to consider.

How did you learn about the STAT EAL SUD Program?

friend, counselor, in rehab, Google search etc.

IF YOU ARE DETERMINED ELIGIBLE FOR THE EQuine Affect™ PROGRAM: you will be required to sign a Program Participant Agreement after which you will be known as a “Program Participant.” The agreement requires all participants to:

attend all 12 week sessions
have their own transportation to/from the program site for 12 sessions
have a minimum of 30 days of sobriety and continue to abstain from using substances (If confirmed or suspected of using substances, the scholarship and services are terminated)
sign additional waivers, confidentiality agreement, authorizations, and documentation as required
complete required inventories and Program Surveys
may also require a referral from a current treating mental health provider and/or substance abuse counselor for agreement of readiness and suitability to participate in this Program

Briefly describe why you want to participate in the EQuine Affect™ Personal Growth and Learning Program for people in SUD recovery:

Grammar does not matter. Just share what you hope.

Healing with Horsepower

Since 2007

Which EQuine Affect™ format: Group or Individual? Are you applying to be in a small group or as an individual in private sessions?

Individual (no group) Small Group

First and Last Name

County of Residence

Current Address

Date of Birth

Age

Gender

Highest Level of Education

Elementary School, Some Junior High School, Junior High School, Some High School, GED, High School Graduate, Vocational Certificate, AA or AS Degree, Some College, College Graduate, Advanced Degree

Are you Employed?

Yes No On Disability Retired

Where and Job Title

Are you a Military Veteran?

Yes No

Branch

Army Air Force Navy Marines Coast Guard

Type of Discharge

Do you receive care through the VA or Vet Center?

Yes No

Did you receive any formal substance abuse treatment in the military?

Yes No

Phone Number

You agree for "STAT" to call and leave a voicemail at listed number to schedule the screening interview?

Yes No

You can be contacted by email

You agree for STAT to respond through Hushmail to your e-mail for scheduling the interview telephone screening appointment?

Yes No

E-mail Address

(Please be mindful of privacy of the e-mail you provide (e.g., personal account, employer, or school etc.)

Do you agree to an encrypted e-mail response?

Yes

(It is secure and HIPAA compliant. You will have to set a password and provide your email on Hushmail's secure message center to view your encrypted message)

(An unencrypted e-mail response is sent directly from Hushmail to your email and is not regarded as secure or private if your personal email account is not already encrypted).

What is your experience with horses?

No experience A little experience A lot of experience A lifetime of experience

What is your confidence level with horses?

Not confident A little confident Very confident Horsemanship confident

What Substance Use Disorder have you been treated for?

What was your substance of choice?

Age you first used:

Are you currently abstaining from substance use?

Yes No

As of today's date, number of days you have been sober/clean?

Number of times you have been in SUD residential treatment

Date of Last Residential Treatment:

What helps you remain sober?

meetings, counseling, spirituality, etc.

How often do you attend AA/NA Meetings?

Never Daily Weekly Monthly When needed I don't currently attend meetings

Do you have a sponsor?

Yes No

Do you have any legal changes pending against you?

Yes No

List legal charges pending

Have you ever been arrested?

Yes No

List your arrest history including date

List all charges

Are you currently on probation or parole?

Yes, Probation Yes, Parole No

What are you on probation or parole for?

Do you have a mental health counselor?

Yes No

Current mental health treatment frequency

weekly, monthly, as needed

Do you have a substance abuse counselor?

Yes No

Current SUD treatment frequency

weekly, monthly, as needed

Diagnoses (By a Licensed Medical Professional)

Medication(s) Prescribed by Medical Provider

Please list any physical limitations

Anything you want to share that is important to know about you?

How important is recovery to you?

Not at all A little Some Very

How confident are you in your recovery to remain sober?

Not at all A little Some Very

By checking this box you understand that: 1) This form is encrypted and HIPAA compliant. 2) Submitting this form and receiving a response does not indicate a professional relationship. 3) Services are for adults at least 18 years old and live in Pennsylvania. 4) All information provided on this form remains confidential.

Thank you for contacting STAT Inc. about the EAL Recovery Program. By submitting this form you attest the information provided is accurate and you are the above named individual. A STAT Team Member will be in touch soon.

Your information will be encrypted.

STAT INC EQuine Affect™ SUD Recovery: Equine Assisted Learning Program

12 WEEKLY TOPICS:

12 WEEKS OF PERSONAL DEVELOPMENT ALONGSIDE HORSES

Veterans: to participate in STAT's Recovery Program for Veterans made possible through the VA Adaptive Sports Grant click on the application link: Veteran Application https://hushforms.com/stat-veteran-programs

Currently, applicants can submit this application to be placed on a WAITLIST, as we await grant funding. We are hopeful to have future funding to offer this program again at no cost.

Program Participation Info

Thank you for contacting STAT Inc. about the EAL Recovery Program. By submitting this form you attest the information provided is accurate and you are the above named individual. A STAT Team Member will be in touch soon.

12 WEEKLY TOPICS:

Healing with Horsepower since 2007