Referral Form

My Name

Preferred Pronouns (optional)

Address

Telephone number

Date of Birth

Please provide contact information of someone we can contact in an emergency, this could be a friend, carer, relative or your GP.

Emergency Contact Name

Emergency Contact Email

Emergency Contact Telephone

What is their relationship to you?

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Please let us know about any needs you have, or a diagnosis if you have one. This will enable us to ensure the group is the right space for you and that we can support you in the best way.

What should I put here?

Anything that would help us in supporting you, for example: hearing impaired, ADHD, Parkinson’s Disease, Stroke, Right side hemiplegia (paralysis), anxiety

Some considerations for you:

Do you have access to a suitable device (laptop, tablet or smartphone)?

Yes

Do you have a stable internet connection to be able to attend sessions?

Yes

Do you have a space where you feel comfortable to take part in the sessions?

Yes

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Keeping your information secure

We are fully committed to keeping everyone safe and following GDPR guidance for online sessions. Sessions will be conducted using the Zoom platform. There will be no personal or sensitive data exchanged over virtual session spaces.

I confirm that I will not audio or video record, nor share, any part of the session. This is to keep our staff and other group attendees’ identities safe.

If you have any concerns about your safety or wellbeing you're welcome to speak with Chiltern's Safeguarding Lead in confidence via safeguarding@chilternmusictherapy.co.uk

I understand that I can access and read Chiltern's Privacy Policy and understand and am satisfied with the level of online security for these sessions

Additional information

Before signing and submitting this form, we would love you to answer the following two optional questions:

How did you hear about Chiltern Music Therapy?

I would like to receive news and information from Chiltern Music Therapy by email, knowing I can opt out at any time.

Submission

By submitting this form, you confirm that you have read, understood, and agree to the terms, conditions, and responsibilities outlined in this form, and that you consent to the referral and any related actions as described.

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Thank you for your application to join our Music Therapy group!

We really appreciate you taking the time to share your information with us. We’ll be reviewing it carefully to make sure our service is the right fit for you.

In the meantime, we’d be grateful if you could take a few minutes to fill out this short Equal Opportunities form. Filling out this form is completely optional. The information you provide helps us ensure our services are inclusive, accessible, and responsive to the diverse needs of everyone who uses them. All information is confidential and used solely for monitoring and improving our services. It will not affect the support or service you receive and will never be shared in a way that identifies you.

What happens next?

You’ll hear from us within the next 2–5 days.
If everything looks good, we’ll send you a confirmation email with details on how to book and pay for your music therapy sessions.
If we need anything else from you, we’ll get in touch directly

In the meantime if you need any other information please contact us directly

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