Music Therapy Referral

7 Briar Road Twickenham TW2 6RB

Music Therapy Direct 020 8744 8097 RMT Office 020 8538 3866 Fax 020 8538 3867

MUSIC THERAPY REFERRAL- Hounslow Short Breaks

Name of Child: ______

Date of Birth: ______Sex: M / F (please circle)

Home languages:______Ethnicity:______

UIN (Unique Identification Number): ______

(If you do not have this number please contact the Short Breaks Team on 020 8583 3636)

Name(s) of Parents/Guardians:______

Address / Postcode:______

Brothers/Sisters (please include DOB):______

______

Are you happy for us to communicate with you per email: Yes No

Email address:______

Telephone Numbers:______

Reasons for referral: Please describe your child’s needs and areas of difficulties.

______

______

______

______

Diagnosis(if known):______

Medication (and reasons):______

Does your child have any condition requiring

special caution by their music therapist? (e.g. epilepsy):______

Does your child receive any other form of therapy?

Please specify:______

Richmond Music Trust is offering blocks of 12 one-to-one music therapy sessions to children through the Hounslow Social Services - Short Breaks Programme.

Sessions take place on Saturdays at the ‘HUB’ (Beavers Library) in Salisbury Road, Hounslow, TW4 7NW. For children who are unable to attend sessions on Saturdays we offer after-school sessions from our premises in 7 Briar Road, Twickenham.

In order to allocate spaces for therapy fairly and most effectively please answer the following questions:

1. Do you live in the London Borough of Hounslow (the borough you pay your council tax to)?

2. Has your child been identified as:

Pathway 1

Pathway 2

Pathway 3

Please tick the appropriate. If you are not sure about which Pathway applies to your child please contact the Hounslow Short Breaks Team.

3. Has your child attended music therapy sessions through Short Breaks before?

(Please state number of sessions)

4. Would you be able to attend music therapy sessions on Saturdays at the ‘HUB’, Hounslow?

5. If yes, are there any times you would not be able to attend?

6. If no, would you able to attend music therapy sessions at 7 Briar Road, Twickenham during after school hours?Please specify possible days / times:

7. Any other relevant comments:

Music Therapy Participation Consent:

I give consent for my child, ______[insert child’s name] to participate in music therapy sessions provided by Richmond Music Trust.

Child’s name:______Relationship to child: ______

Date: ______Signed: ______

Please return to:Andreas Rosenboom, Head of Music Therapy,

Richmond Music Trust, 7 Briar Road, Twickenham, TW2 6RB

Thank you for completing this referral form. All information given will remain strictly confidential. You may be contacted shortly to discuss the referral in more detail.

Chief Executive: Chris Cull

Registered Charity No. 1090623 Company Number. 4218180