MAIN STAY THERAPEUTIC FARM      6919 KEYSTONE RD    RICHMOND IL, 60071    815.653.9374   CONTACT US

DONATE To encourage, enrich and empower individuals through the therapeutic benefits of horses, animals and nature in an uplifting and nurturing setting. Main Stay is a place where bodies are challenged, minds embrace possibilities, and spirits are renewed.

 

Consent for Release of Information

Periodically we may want to consult with other agencies/therapists with which you are working. Please provide their name(s) and address(es) below.

I hereby authorize

(please list all institutions associated with the client)
(complete address and phone number of person(s) and/or facility)

to release information from the records of

The information is to be released to Main Stay Therapeutic Farm for the purpose of developing a therapeutic riding program and/or animal assisted learning program for the above named client. The information to be released is marked below.

This release is valid for one year and can be revoked in writing, at my request. Please send materials to the address listed above.

Contact information

Main Stay Therapeutic Farm

6919 Keystone Rd., Richmond, IL 60071

Tel: 815.653.9374  Fax: 815.728.1224

Contact Us

info@mainstayfarm.org

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