Patient Forms

INTRODUCTION TO THE THERAPEUTIC FARM PROGRAM

Fraley & Associates, PLLC, dba Legend Equine Facilitated Therapy Program, is a private non-profit organization founded by Lynn A. Fraley, MEd, with the mission of providing growth and change through a variety of social services. Our programs are funded by private insurances, donations, grants and through fees for services. Services are offered regardless of ability to pay and fees are negotiated on that basis.

VALUES:
At Fraley & Associates, PLLC we promote the following values:

  1. Safety for all participants both human and animal;
  2. Respect;
  3. Courage to try new things without judging the outcome;
  4. Cooperation and negotiation;
  5. Personal growth
  6. Learning;
  7. Balance, consistency and flexibility; and
  8. Responsibility

We believe that through the process of building relationships with animals and the natural environment an individual can come to know self better. This process also allows individuals to develop and improve communication with others and to manage the expression of feelings with greater clarity.

GOALS:
It is important to us that we provide a safe environment in which to:

  1. Discover and nurture strengths, interests and talents;
  2. Support efforts toward change;
  3. Establish consistent and stable relationships;
  4. Improve interpersonal skills;
  5. Enhance self worth and empowerment;
  6. Identify and develop individual learning styles;
  7. Gain knowledge and learn to emulate communication skills through farm experiences;
  8. Conduct Equine Assisted Activities/Equine Assisted Therapy (EAA/EAT)

CONSIDERATIONS:
You will be introduced to safety aspects of being around animals during your initial sessions. Attention to safety issues by all involved will be a regular part of each session. If you are a parent/guardian of a program participant, your interest in the in the process and activities is important. Please notify the therapist of any significant behavioural/emotional or physical changes that may impact activities.

It is important for us to have an understanding of the participant’s physical strengths and weaknesses. This information might include flexibility, hearing/sight impairments, endurance, balance, allergies, skin sensitivities, cardiac problems and dexterity. Please let us know of any problems, which may arise during physical activities so that we may develop sessions accordingly.

We wish to keep participation in our program a productive experience for all. Physical contact between participants does occur. It is our expectation that everyone (staff and participants) will maintain appropriate physical and personal boundaries.

Program participants should wear clothing suitable to being in a barn and animal-oriented environment. We will assist you to meet this standard in any way we can. The therapist will discuss the particulars of this with you prior to your first session. A session will not proceed if the participant’s clothing is unsuitable.

AGREEMENT
I agree to be responsible for my physical, spiritual, mental and emotional safety, and in that way, add to the safety of all involved.

Participant:
Signature:
Date:
Parent/Guardian:
Signature:
Date:
Program Personnel:

Authorization For Emergency Medical Treatment

Name:
DOB:
Phone:
Address:
Physicians Name:
Medical Facility:
Health Insurance Co:
Policy Number:
Allergies to Medications:
Current Medications:

In the event of emergency contact:

Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:

In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, I authorize Fraley & Associates, PLLC to:

  1. Secure and retain medical treatment and transportation if needed; and
  2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment

Consent Plan

This authorization includes x-rays, surgery, hospitalization, medication and any treatment procedure deemed “life saving” by the physician. This provision will only be invoked if the person(s) above is unable to be reached.

Participant:
Consent Signature:
Date:
Client:
Consent Signature:
Date:
Parent or Legal Guardian:
Consent Signature:
Date:
Signed in the presence of personnel:

Non-Consent Plan

I do not give my consent for emergency treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency. In the event emergency treatment/aid is required, I wish the following procedures to take place:

Participant:
Consent Signature:
Date:
Client:
Consent Signature:
Date:
Parent or Legal Guardian:
Consent Signature:
Date:
Signed in the presence of personnel:

Adult Participant Release of Liability Agreement

I,
For in consideration of the agreement of Fraley & Associates, PLLC and Legend Equine Facilitated Therapy Program to provide Equine Assisted Activities/Equine Assisted Therapy to myself, do hereby forever release, acquit, discharge and hold harmless Fraley & Associates, PLLC and Legend Equine Facilitated Therapy Program, its officers, trustees, agents, employees, representatives, successors and assigns, for all manner of claims, demands, and damages of every kind and nature whatsoever, which the undersigned may now, or in the future have against Fraley & Associates, PLLC and Legend Equine Facilitated Therapy Program, its officers, trustees, agents, employees, representatives, successors or assigns on account of any personal injuries, physical or mental condition, known or unknown to the undersigned and the treatment therefor as a result of, or in any way growing out of, the acts of Fraley & Associates, PLLC and Legend Equine Facilitated Therapy Program, it’s officers, trustees, agents, employees, representatives, successors or assigns, including but not limited to, their negligence or gross negligence , in rendering the services above described or in any way incidental thereto.

UNDER IDAHO LAW, AN EQUINE ACTIVITY SPONSOR IS NOT LIABLE FOR AN INJURY TO, OR THE DEATH OF, A PARTCIPIPANT IN EQUINE ACTIVITIES RESULTING FROM THE INHERENT RISKS OF EQUINE ACTIVITIES THAT ARE OBVIOUS AND NECESSARY.

Participant:
Signature:
Date:
Parent/Guardian:
Signature:
Date:
Program personal:

Child Participant Release of Liability Agreement

I ,
for an in consideration of the agreement of Fraley & Associates, PLLC to provide Equine Assisted Activities/Equine Assisted Therapy to (child participant).

do hereby forever release, acquit, discharge and hold harmless Fraley & Associates, PLLC, its officers, trustees, agents, employees, representatives, successors and assigns, for all manner of claims, demands, and damages of every kind and nature whatsoever, which the undersigned or said minor may now, or in the future, have against Fraley & Associates, PLLC, its officers trustees, agents, employees, representatives, successors or assigns on account of any personal injuries, physical or mental condition, known or unknown, to the person of said minor and the treatment thereafter as a result of, or in any way grow out of, successors or assigns, including but not limited to, their negligence or gross negligence, in rendering the services above described or in any way incidental thereto.

UNDER IDAHO LAW, AN EQUINE ACTIVITY SPONSOR IS NOT LIABLE FOR AN INJURY TO, OR THE DEATH OF, A PARTICIPANT IN EQUINE ACTVITIES RESULTING FROM THE INHERENT RISKS OF EQUINE ACTVITIES THAT ARE OBVIOUS AND NECESSARY.

Participant:
Signature:
Date:
Parent/Guardian:
Signature:
Date:
Program personal:

HORSE RELATED ACTIVITIES COME WITH THIS WARNING

SECTION A. PROTECTIVE ATTIRE

  1. I am hereby advised to always wear hard soled, full enclosed shoes or boots and socks to protect feet and long pants to protect legs while working around or interacting with horses.

SECTION B. THE NATURE AND PHYSICAL CHARACTER OF THE HORSE:
Domesticated, well-trained horses are usually obedient, docile and affectionate. However it is important to understand that their survival instinct are what have allowed the horse to survive from prehistoric times to the present day.

  1. I am advised that horses are unpredictable by nature, with minds of their own, as are all animals, both domestic and wild. The horse is often somewhat high strung or nervous by nature. Horses are extremely strong and physically powerful. Horses are extremely heavy weighing from 600 – 1300 lbs on average. These characteristics deserve a human being’s utmost respect.
  2. I am advised that when a horse is frightened, angry or under stress or feels threatened, it is the horse’s instinct to jump forward or sideways, to run away from danger at a trot or gallop up to speeds of 35 miles per hour.
  3. I am advised that if a horse is frightened or feels threatened from behind, the horse may kick straight back, sideway in either direction or even forward with either or both hind legs with tremendous force.
  4. I am advised if a horse is frightened or feels threatened from above or from his/her back he/she may hunch the back and buck in a way that could throw a rider to the ground with tremendous force. A fall from a horse will usually be from a height of 3 - 6 feet.
  5. I am advised that is a horse is frightened or feels threatened from the front, the natural reaction may be to rear up with both front legs, strike with one or both front legs, bite with teeth, throw the head up or from side to side, or run directly over whatever he/she fears in front of him/her.
  6. I am advised that a human must always approach a horse calmly and quietly with caution, preferably to the horse’s shoulder or lower neck, talking soothingly to the horse.
  7. I am advised that loud and/or sudden unexpected movements, dropping of objects near a horse, approaching vehicles or animals or people, ill fitting equipment or physical pain can provoke a domesticated horse to react according to natural protective instincts.
  8. I am advised that the first signs of anger or fear in a horse are the sudden tensing of the muscles in the body, perhaps laying the ears flat back against the head, or quickly tossing or raising the head, or suddenly snorting though the nostrils accompanying at least one other warning signs.
  9. I am advised that a horse can see independently with each eye, actually looking in one direction with one eye and another direction with the other eye. The horse can also focus both eyes on one object somewhere in front of him/her. Typically the direction the ear is pointing will tell the observer where the eye is looking on the other side.
  10. I am advised that a horse has two blind areas around which he/she cannot see. There areas are directly behind the horse and directly in front. When a horse his/her head lowered to the ground the spot directly at the end of the nostrils is a blind area. This is the reason it is best to approach a horse close to the shoulder and never surprise a horse from the rear, or to reach first for the horse’s mouth.
  11. I am advised that while a horse is very sure-footed by nature, horses may accidentally step on an object such as a human’s foot when the horse is balancing or turning around. When a horse is worked on unstable ground or slippery grass or footing, the horse could fall down injuring the rider and/or handler.

I have read and understand the above warnings concerning protective attire and the nature and physical character of the horse.

Participant:
Signature:
Date:
Parent/Guardian:
Signature:
Date:
Program personal: