Intake | The JAYC Foundation

Thank you for your interest in joining our directory of providers. To submit your organization, please complete the form below. Note: Completion of the form does not guarantee acceptance into the directory.

Your Name

Your Website URL

Your Company Name

Your Company Phone Number

Your Company Address

Your Email Address

Please Describe Your Practice in 3 Sentences or Less (300 Characters Max).

Please Describe Your Experience Working With Animals in 3 Sentences or Less (300 Characters Max).

Animals Incorporated (Select All That Apply): Animals Incorporated (Select All That Apply): Birds Cats Dogs Farm Animals Fish Horses

Equine Work (Select All That Apply): Equine Work (Select All That Apply): Ground-Based (No Riding) Mounted

Ages Served (Select All That Apply): Ages Served (Select All That Apply): Children (0-12) Adolescents /Teens (13-17) Young Adults (18-25) Adults (26-50) Older Adults (50+)

Provider Type (Select All That Apply): Provider Type (Select All That Apply): Therapist / Licensed Mental Health Provider (LMFT, LCSW, LPC, Psychologist, Psychiatrist) Life Coach Equine Specialist / Equine-Assisted Professional Animal Specialist / Animal Assisted Professional Other Helping Professional (OT, PT, Educator, etc)

Specialized Populations Served (Select All That Apply): Specialized Populations Served (Select All That Apply): Military First Responders Victims of Sexual / Physical Violence LGBTQ+ Neurodiversity

Is Your Facility Wheel Chair Accessible? Is Your Facility Wheel Chair Accessible? Yes No

Session Types Offered to Clients (Select All That Apply): Session Types Offered to Clients (Select All That Apply): Individuals Couples Families Groups

Do You Offer Virtual Sessions With Clients? Do You Offer Virtual Sessions With Clients? Yes No

Do You Accept Insurance as a Form of Payment? Do You Accept Insurance as a Form of Payment? Yes No

Have You Completed Any Training From Polyvagal Equine Institute? Have You Completed Any Training From Polyvagal Equine Institute? Yes No

Do You Agree to Offer 25% off Services to Clients Referred Through the Hooves for Helping Program? Do You Agree to Offer 25% off Services to Clients Referred Through the Hooves for Helping Program? Yes No

Are You Interested in Learning More About the PVEI Year-Long Program? Are You Interested in Learning More About the PVEI Year-Long Program? Yes No Maybe

Do You Certify That All of the Information You Have Provided Is Accurate? Do You Certify That All of the Information You Have Provided Is Accurate? Yes No

If Approved, Do You Agree to Notify The JAYC Foundation Immediately Should Any of Your Information Change? If Approved, Do You Agree to Notify The JAYC Foundation Immediately Should Any of Your Information Change? Yes No

Upload Professional Headshot Photo for Profile Please select a high quality photo that is at least 400x400 pixels in size. The photo should only have 1 person in it.File InputNo Image ChosenAccepted image file types: jpg, jpeg, jpe, png. Max. image file size: 5 MB

Upload Organization Logo for Profile Please select a high quality image that is at least 800x600 pixels in size.File InputNo Image ChosenAccepted image file types: jpg, jpeg, jpe, png. Max. image file size: 5 MB

Complimentary Shirt Size (American Standard Sizes) If approved for the directory, a complimentary T-shirt will be provided as thanks for joining (while supplies last).

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