Music Therapy Referral Form (Child)

This form is to be completed by a parent/carer of the child.
Referral Number
CHILD'S DETAILS
Child's Name*
First Last
Date of Birth*
Date Format: DD slash MM slash YYYY
Diagnosis*
REASON FOR REFERRAL
What goals would you like to focus on in music therapy?*
Describe your child’s communication/social skills (such as preverbal & verbal skills, ability to relate to others):
Describe your child’s level of comprehension/cognition (such as receptive & expressive language ability):
Describe your child’s sensory abilities/difficulties (such as vision, hearing, touch):
Describe your child’s physical mobility (such as ability to walk, use of wheelchair):
Psychological/emotional/behavioural characteristics (confidence, ability to express self, anxiety, aggression):
Musical interests and skills observed (vocal and movement/rhythmic responses, styles of music, musical instruments, how does your child respond to music):
Does your child receive other therapeutic interventions (occupational therapy, speech therapy)? If so, what goals are being addressed?
Please supply relevant information which may assist us to understand your child better (psychological assessment report, occupational therapy report, speech therapy report)
Any other information:
GETTING TO KNOW YOUR CHILD
When I hear music, I...
Musical instruments I have at home are...
The best way you can help me learn new things is by... (Step instructions? Visual cues? Modelling?)
I really love… (Music? Dancing? Computer games? Outdoor play?)
When I am doing something I love, I can do that for (how long)?
I don’t like… (Loud noise? Large crowds? Being out of routine?)
I express what I want and what I don’t want by…
When I feel happy/upset/angry, I can express my feelings by...
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*
Your child will be accessing this service through:*
Please Specify*
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*
Phone
This field is for validation purposes and should be left unchanged.

Music Therapy Referral Form (Child)

CHILD'S DETAILS

REASON FOR REFERRAL

GETTING TO KNOW YOUR CHILD

AVAILABILITY

PARENT/CARER'S DETAILS