Hippotherapy Application

Please see the image at the bottom of our form to help you differentiate between Hippotherapy and Adaptive Riding

Medical History

Client must have a physical or mental health condition to apply for STAT®'s Hippotherapy program. This is not horseback riding lessons, sessions are facilitated by a licensed Physical, Occupational or Speech Therapist.

PLEASE TYPE DIAGNOSIS IN BOX ABOVE

The applicant understands that a medical or a mental health diagnosis is required for Hippotherapy

Yes No

Client Information

First name

Last name

Age

Date of birth

Check this box if the client is a minor or has a legal guardian

Email address of parent/guardian or adult applicant:

Contact phone number

Parent or Guardian Information

First name

Last name

Home phone number

Cell phone number

Email address

Address:

Relationship to child

Is the client currently under the care of a medical provider or is there anything else of importance that you want to tell us? Please describe below.

A staff member will be in touch. If you have questions, please feel free to contact STAT® at 833-328-7828 or via email at cmarkosky@statinc.org. If you submit this application, please allow 3 business days for a therapist to contact you. If you do not hear from a therapist within 4 business days, please contact STAT® via TEXT at 833-328-7828. Hippotherapy/adaptive riding sessions are $75. We strongly encourage weekly sessions. If you require financial assistance, we can assist with grant funding support when it's available and once you are a client of STAT®. Out of pocket rates are discounted 20% upon request.

Email address

AR vs. HPO

This is an image to help you decipher the difference between STAT's Adaptive Riding and STAT's Hippotherapy Programming

Your information will be encrypted.

Hippotherapy Application

Please see the image at the bottom of our form to help you differentiate between Hippotherapy and Adaptive Riding

Medical History

Client Information

Parent or Guardian Information

Please see the image at the bottom of our form to help you differentiate between Hippotherapy and Adaptive Riding

STAT® Inc.

Healing With Horsepower since 2007