Music Therapy Referral Form (Child)

This form is to be completed by a parent/carer of the child.
The information you provide will be used to develop a person-centred description of your child’s strengths and needs, inform our clinical planning, focus for assessment and connecting you with a therapist in our team best suited to meet your child’s needs.
All information provided is confidential.
Referral Number
CHILD'S DETAILS
Child's Name*
First Last
Date of Birth*
DD slash MM slash YYYY
Diagnosis or relevant health/medical background*
What goals would you like to focus on in music therapy?*
COMMUNICATION NEEDS
Are there any communication needs where it would be useful to know your cultural background?*
- Yes
- No
What is your cultural background?*
Language/s spoken:*
Do you need an interpreter?*
- Yes
- No
GETTING TO KNOW YOUR CHILD
Section A:
The following information will give us some background knowledge of your child’s developmental and functional skills.
Please describe your child’s cognitive skills (such as attention, information processing, memory, auditory and visual processing, listening skills)*
Please describe your child’s communication skills - how your child communicates their needs (such as verbal, non-verbal, expressive and receptive language, augmentative and alternative communication strategies or methods already in place)*
Please describe any emotional/psychological/behavioural characteristics or concerns (such as trauma, anxiety, aggression, withdrawal, lack of confidence, behaviours you suspect may come from emotions or difficulty with a functional aspect of the task or communication)
Please describe your child’s mobility and motor skills (such as gross motor, fine motor, coordination, balance, fatigue)*
Please describe any sensory needs your child has that we should be aware of (such as being over or under responsive to external stimuli, stimming behaviours, vision or hearing impairments, sensitivities to touch, sounds, light, temperature)*
Please describe your child’s social skills (such as play skills, interest in others, challenges or barriers to forming and maintaining relationships, joint attention, turn taking)*
Please describe any preferences/specific responses your child has to music (such as musical styles, artists, a particular song, natural talent, use of technology)
Section B:
Please complete the following statements as you think your child would respond.
Who completed this section*
When I hear music, I...*
I really love…*
When I focus on an activity (that’s not something I might usually fixate on), I can do that for (how long)...*
I don’t like…*
I express what I want and what I don’t want by…*
The best way you can help me feel safe and learn new things is by...*
Section C:
Please complete the following statements as you think your child would respond.
Do you have a preference of therapist, or any requests regarding specific training and experience?
Is there any other information you would like to add? (such as details on medical or support history)
ACCESSING MUSIC THERAPY
I would like my child to access the following service/s:*
- Music Therapy - Individual
- Music Therapy - Group
- I just want an initial consultation only
My child will be accessing this service through:*
Please Specify*
AVAILABILITY
Availability for weekly sessions:*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
(Monday) time/s available*
(Tuesday) time/s available*
(Wednesday) time/s available*
(Thursday) time/s available*
(Friday) time/s available*
(Saturday) time/s available*
PARENT/CARER'S DETAILS
Parent/Carer's Name*
First Last
Relationship to the Child:*
Address*
Street City State Postcode
Phone*
Email*
How did you find out about Sound Expression?*
Terms and Conditions*
- I have read and understood the Terms & Conditions and any questions I have asked have been answered to my satisfaction*
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Email
This field is for validation purposes and should be left unchanged.

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Music Therapy Referral Form (Child)

CHILD'S DETAILS

COMMUNICATION NEEDS

GETTING TO KNOW YOUR CHILD

Section A:

Section B:

Section C:

ACCESSING MUSIC THERAPY

AVAILABILITY

PARENT/CARER'S DETAILS