Intake Form: Equine-Assisted Psychotherapy

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Thank you for your interest in mental health and wellness services at Haku Baldwin Center. To apply, complete this short intake form below. Our staff will then contact you to discuss the next steps.

Equine-Assisted Psychotherapy (EAP)

- Provided by Licensed Mental Health Professionals and incorporates horses
- All unmounted. No horse riding involved.
- Includes individual support, family support services, and group sessions
- Addresses mental health and wellbeing while mitigating the heightened risks of burnout, moral injury, anxiety, depression, family dysfunction, addictive behaviors, post traumatic stress disorder, recurring memories, sleeplessness, loss of interest, nightmares, and hypervigilance

- Minimum age for individual sessions: 12 years old
- Minimum age for family or group sessions: 4 years old*
*All ages must be able to be safe around horses on the ground

SCHOLARSHIP ELIGIBILITY:
Thanks to community partners like the Maui Strong Fund by the Hawai'i Community Foundation, some of our mental health services are provided at no cost to clients. Please complete this form to help determine your eligibility.

Contact Program Director Chrissy Stout at chrissy@hakubaldwincenter.org with any questions. Phone calls are welcome by appointment.

Haku Baldwin Center is a registered 501(3)(c) nonprofit organization located in Upcountry Maui
Tax ID No. 99-0292754

Your Email *

Your First Name *

Your Last Name *

Your Phone Number *

Is it okay to text you? *

Yes

Organization Name & Role (if applicable)

Street or Mailing Address

Session type *

Family sessions

Individual (for myself)

Individual (for a family member)

Individual (for a client)

Group sessions (non-family)

Other:

Required

Session options *

Equine-Assisted Psychotherapy (with a licensed mental health professional)

Equine-Assisted Learning (non-therapy service with a certified instructor/facilitator)

Both

Required

Duration *

One-time session

Multiple sessions, e.g. weekly or every other week

Ongoing basis

I am not sure and would like to try an introductory session first

COST & SCHOLARSHIP ELIGIBILITY
Some sessions may be fully or partially subsidized for eligible participants through our community partnerships.

Please review the information below and select any options that apply to you, your family member(s), or group participants. We may follow up for additional information to determine eligibility.

Note: Subsidized rates are subject to the availability of funding at the time of registration.

Cost Information:
-Insurance: HBC does not currently accept insurance.
-Scholarship: You may qualify for free or reduced-cost services through community-based funding.
-Direct Pay (Individual Session): $200 per hour
-Direct Pay (Group Session):
$300 for groups of 2–5 participants
$400 for groups of 6–10 participants

Regardless of payment method, please select options below to help us assess eligibility.
SELECT ALL THAT APPLY.

Current Maui County resident

Native Hawaiian or indigenous persons

Current or former Lahaina area resident impacted by the Maui Wildfire Disaster

Current or former Kula area resident impacted by the Maui Wildfire Disaster

First responder or family member of a first responder

U.S. military (active duty, retired, or disabled)

At-risk youth or youth with Adverse Childhood Experiences (ACEs)

Victim or survivor of crime or violence

LGBTQ+ individual facing barriers to services

Individual with a physical, sensory, intellectual, or mental health disability

Low-income individual or family

None of these apply

Other:

Required

What are the presenting problem(s) or reason(s) for seeking services? Please be as specific as possible.

Reminder: this form is confidential.

(Required for Individual Sessions)
List the name and date of birth for the individual participating in the session(s).

(Required for Family Sessions)
List the names and dates of birth for those participating in the session(s).

(Required for Group Sessions)
List the names and ages/age range of those participating in the session(s).

NOTE: If names of group members are unknown, please provide an estimate for the # of people, and age range below. THEN, email the group or client roster at least 48 hours prior to a scheduled session, to chrissy@hakubaldwincenter.org

I understand that no horse experience is necessary to participate in equine-assisted services, though participants do need to be able to safely be around horses on the ground. *

Yes

I acknowledge that by completing this inquiry form, I am NOT obligated to participate in any therapy or non-therapy sessions, AND that additional forms would be required to register for services, (e.g. waiver and consent forms). *

Yes

How did you hear about or organization?
(i.e. Google, Social Media, Referral, etc.)
*

Google

Social Media

Referral

Word of Mouth

Current or former HBC program participant or client

Other:

Use this space for any questions about this program or to provide any additional information about yourself, your family, or your group.

Today's Date *

YYYY

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