Refer a Child/Young Person - Richmond Music Trust

This form should be used to refer a child or young person aged under 18 for Music Therapy. All information given will be treated as confidential.

Email address to be used as first point of contact with regard to this referral*

Child's Details

Name of Child*

First Last

Date of Birth*

Home Languages*

Address*

Street Address Address Line 2 City Post code

Parent/Guardian Details

Is the Parent/Guardian the referrer?*

Yes
No

Parent/Guardian Name*

First Last

Parent/Guardian Email*

Parent/Guardian Phone*

Home Address (where different from child's address)

Street Address Address Line 2 City Post Code

I would prefer to be contacted by*

Email
Phone
Post

Referred Child's sibling(s) and Date(s) of Birth

Alternative Referrer Details

This section need only be completed when the Referrer is NOT the Parent/Guardian.

Name of Referrer (where this is NOT the parent/guardian)

First Last

Relationship of Referrer to the child (where this is NOT the parent/guardian)

Phone number of the Referrer (where this is NOT the parent/guardian)

Email of the Referrer (where this is NOT the parent/guardian)

Address of the Referrer (where this is NOT the parent/guardian)

Street Address Address Line 2 City Post code

School/Nursery Details

School/Nursery Name

School/Nursery Email

Keyperson Name

First Last

Location/Availability for Therapy

What kind of sessions do you require?*

One to One
Group

Where would you like sessions to take place?*

When are you available for sessions to take place?

Please use this box to give exact time frames which suit you, e.g. Mon after 4pm

More Information on the Referred Child

Your reason(s) for referring*

Referred Child's Diagnosis

Referred Child's Medications

Other therapies received

Conditions requiring additional caution on the part of the Therapist (eg epilepsy/challenging behaviour)

Other Professionals involved

Invoicing

Invoice Name*

First Last

Position

Email*

Phone

Invoice Address (including postcode)*

Street Address Address Line 2 City Post Code

I would prefer to be invoiced each*

Your Consent

I confirm that I have read and agree to the Terms and Conditions on this page and that I consent to RMT using my personal information as outlined in the RMT Privacy Notice*

Yes
No

RMT Privacy Notice (opens in a new tab)

Your Name*

First Last

Today's Date*