Referral Form

Please note that for the purposes of this form we are using the term 'client' for the person attending the group and you are the referrer.

Client's Name

Client's Preferred Pronouns (optional)

Client's Address

Client's Email

Client's Telephone number

Client's Date of Birth

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Referrer's Name

Referrer's Email

Referrer's Telephone

What is your relationship to the client?

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Please let us know about any needs your client has or a diagnosis if they 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:

Does your client have access to a suitable device (laptop, tablet or smartphone)?

Yes

Does your client have a stable internet connection to be able to attend sessions?

Yes

Does your client have a space where they 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:

Would you the referrer or your client like to receive news and information from Chiltern Music Therapy by email, knowing I can opt out at any time.

Referrer

Yes

Client

Yes

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!

What happens next?