PROFESSIONAL REFERRAL FORM

Professional Referral Form
Dear Professional,

Hope Haven is a non-profit, charitable organization that provides specialized equestrian programs for individuals with disabilities and diverse needs. Program options include Adaptive Riding and Horsemanship, Physiotherapy (hippotherapy), Equine Assisted Learning as well as day program and camp opportunities. In order to provide the safest and most effective programming possible, as well as to abide by our charitable status, we require a professional referral to indicate why this individual is appropriate, how they may benefit as well as to make sure their medical history does not place them at risk. This form may also be used to provide consent for a participant's return following a medical leave.

If your client has any physical conditions or medical concerns that may impact their participation at Hope Haven, you must be a physician or nurse practitioner completing this form.

If your client does not have any physical or medical concerns, you may fall under one of these titles: physiotherapist, occupational therapist, speech pathologist, social worker, psychologist, teacher or support worker.

Please review the list of contraindications and precautions below and highlight any that are relevant for your client. Please note that if their diagnosis requires proof of atlanto-axial stability, the results of the x-ray must be indicated on this form.

If you have any questions, concerns or would like to discuss your client in more detail, please contact Hope Haven office directly. You can also visit our website to learn about our programs, staff and our facility.

Thank you for your time assisting your client on their way to achieving success at Hope Haven!

Sincerely,

Gretel Stanish
Program Manager
519-986-1247
gstanishhopehavencentre.org
www.hopehavencentre.org
Professional Referral Form
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Professional's Name*

First NameLast Name
Designation*
MD, PT, OT, SLP, SW. etc
Professional's Phone*

Area CodePhone Number
Professional's Email
example@example.com
List your client's diagnoses and/or social-emotional needs.*
Describe why you think your client may benefit from Hope Haven programs with regards to their disabilities or unique needs?
If your client is returning to Hope Haven from a medical leave, please indicate reason for leave and any precautions for returning. (Physician Only)
After reviewing the contraindications and precautions below, in my opinion I believe this client is appropriate and would benefit from:*

ON Horseback programmingOFF Horseback programming
Atlanto-Axial Verification (Physician Only)

X-ray is negative, does not indicate instabilityX-ray indicates instability, not suitable for On Horseback programming
Date of X-ray
(m/d/y)
Professional Signature*

Clear
Date of Signature*

MonthDayYear
Date
ABSOLUTE CONTRAINDICATIONS (On Horse)

Orthopedic
- Acute arthritis
- Acute herniated or prolapsed disc
- Atlanto-axial instability (Down Syndrome)
- Coxa arthrosis (degeneration of hip joint)
- Structural cranial deficits
- Osteogenesis imperfecta
- Pathological fractures
- Spondylolisthesis
- Structural scoliosis > 30 degrees, excessive kyphosis or lordosis or hemivertebra
- Spinal stenosis
- Hip subluxation, dislocation or dysplasia (one hip)
Neurological
- CVA secondary to unclipped aneurysm or angioma
- Paralysis due to spinal cord injury above T6 (adult)
- Spina bifida associations – Chiari II malformations, hydromyelia, tethered cord
- Recent, uncontrolled seizures
RELATIVE CONTRAINDICATIONS & PRECAUTIONS (On Horse)

Orthopedic
- Arthrogryposis
- Heterotopic ossification
- Osteoporosis
- Spinal fusion/fixation, Harrington Rod (within 2 years of surgery)
- Spinal instabilities/abnormalities
- Spinal orthoses
Neurological
- Amyotrophic Lateral Sclerosis
- Fibromyalgia
- Guillain Barre Syndrome
- Exacerbation of Multiple Sclerosis
- Post Polio Syndrome
- Hydrocephalic shunt
Medical/Psychosocial
- Abuse or disruptive behaviour
- Cancer
- Hemophilia
- History of skin breakdown or skin grafts
- Abnormal fatigue
- Incontinence (must wear protection)
- Peripheral vascular disease
- Sensory deficits
- Serious heart condition or hypertension
- Significant allergies
- Surgery within the last 3 months
- Uncontrolled diabetes
- Indwelling catheter
- Substance abuse
- Anticoagulants (bleeding risk)
Other
- Age under 2 years old
- Any condition that the Instructor, therapist, physician or program does not feel comfortable accepting
ATLANTO-AXIAL X-RAY - Required for atraumatic factors that may be associated wtih an unstable upper cervical spine:
- Down Syndrome
- OS odontoideum
- Athetoid cerebral palsy
- Rheumatoid arthritis of cervical vertebrae
- Congenital torticollis
- Sprengel’s deformity
- Ankylosing spondylitis
- Congenital atlanto-occipital instability
- Klippel-Feil syndrome
- Chiari malformation with condylar hyperplasia
- Fusion of C2-C3
- Lateral mass degeneration change at C1-C2
- Systemic lupus
- Morquio disease
- Non-rheumatoid cranial settling
- Subluxation of upper cervical vertebrae due to tumors or infection
- Idiopathic laxity of the ligaments
- Grisel’s syndrome
- Lesch-Nyhan syndrome
- Marshall-Smith syndrome
- Diffuse idiopathic hyperostosis
- Congenital chondrodysplasia
Should be Empty:

Professional Referral Form

Professional Referral Form