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Prospective Client Registration Form

Thank you for your interest in our Ranch programs. Please read thru the following information before starting your form:

1. If you think you may have signed up in the past for Affinity Ranch (Praying Hands or Promise), please contact our Office at 303-841-4043 and we can update your record instead of creating a duplicate. Since we process our records based on date entered, you may slide farther down the list if you create a duplicate.

2. To facilitate placement with an appropriate provider, information submitted through this form may be reviewed by Affinity Ranch intake staff and participating providers offering the services you request.

3. FOR MENTAL HEALTH SERVICES: This waitlist is intended for individuals seeking future services and is not a crisis response service. Placement on this waitlist does not establish a therapeutic relationship, guarantee services, or ensure immediate contact from a provider. Wait times may vary depending on provider availability.

If you are experiencing a mental health emergency, are having thoughts of harming yourself or others, or require immediate assistance, please do not wait for contact from a provider on this waitlist. Instead, seek immediate help by:

  • Calling 911 or going to your nearest emergency room
  • Calling or texting the 988 Suicide & Crisis Lifeline at 988
  • Contacting your local crisis center or mobile crisis team

By submitting this form, you acknowledge that this waitlist is not an emergency service and that you are responsible for seeking immediate assistance through the resources above if you are in crisis.

 

So we can customize your questions, please answer these questions before continuing: One form per client.

Clients First Name
Clients Last Name
Programs You are Interested In? Check all that apply

Not sure what a service is, just hover over the service title.
Adaptive Horsemanship Horsemanship and riding lessons adapted to the client’s ability


Equine Assisted Therapy (aka Hippotherapy) - please select type(s) of therapyPhysical, Occupational, or Speech therapy while horse mounted or unmounted
    Occupational TherapyImprovement in Skills for daily activity/livin

    Physical TherapyImprovement in Physical function.

    Speech TherapyImprovement in communication, language and cognitive function.

Equine Assisted Learning An experiential learning technique that facilitates personal growth by teaching social, emotional, and life skills through horsemanship

Mental Health Psychotherapy with an equine partner where appropriate

    **Our Mental Health Providers are in network with Aetna, Cigna, Anthem. Blue Cross Blue Shield, United Healthcare, CO Access (medicaid), CCHA (medicaid), Denver Health Medicaid.  We also accept the following grant funds- second wind fund, Victims Compensation. **

Supported Employment Prevocational training, Job Development, and Job Coaching for adults with intellectual disabilities.


Veterans Programs


Are you completing this form for yourself? Yes      No
Is the Client covered under a Community Based Provider? Yes (Developmental Pathways, Rocky Mountain Human Services) No
Does the Client have a current ABA Provider? Yes      No