Consent for Equine Assisted Psychological Services

Child's name *

DOB *//

Gender *

Parent 1 Name *

Parent 2 Name

Parent 1 Mobile number *

Parent 2 Mobile number

Parent Email *

Parent name (claimant) *

Parent DOB *//

Parent Medicare Card Number *

Parent Medicare Card Position *

Parent Medicare Card Expiry *

Child Medicare Card Number *

Child Medicare Card Position *

Child Medicare Card Expiry *

GP Name & Address

GP telephone

Please describe the reason for your referral

What would be the best outcome you could imagine for your child?

How did you hear about rehab4rehab?

Our charity needs your help

We already have a waiting list of families who cannot afford equine therapy. They do not yet have a diagnosis which means:

• no mental health plan or
• they do have a mental health plan BUT, it may not cover equine therapy