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Canine-Assisted Play Therapy

Counseling Referral Form

Hope and Healing for Kids and Canines

Canine-Assisted Therapy

This is an online referral form for the Hope and Healing for Kids and Canines study. The study will explore the difference between counseling with a therapist (only) and counseling with a therapy dog team (therapist and a dog). Potential clients for this study are youth ages 10 to 18 who are struggling with family issues, grief, or other concerns affecting their health and well-being. Youth will participate in 10 sessions of free counseling at the Texas State University Assessment and Counseling Clinic in San Marcos. 

May we leave a message at this number? *
May we leave a message at this number?
May we contact you via email? *

Does the child have any of the following?

Animal Allergies? *
Animal fears or phobias? *
History of aggression or abuse toward animals? *

Please describe...

Would this child like to participate in counseling and/or animal-assisted therapy? *

Appointment Information:

Appt. day/times available (Check Best Options): *