Referral Form - Existing

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.

Name of Existing Service

Name of Therapist at the Service

Client's Name

Client's Preferred Pronouns (optional)

Client's Date of Birth

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Please provide your contact details in this section.

Referrer's Name

Referrer's Preferred Pronouns (optional)

Referrer's Email

Referrer's Telephone

What is your relationship to the client?

Do you have any accessiblity issues we need to be aware of?

How would you prefer to be contacted?

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Please let us know your client's reasons for wanting to access music therapy

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

Please let us know if your client has any accessibility needs or preferences

Tick to confirm your understanding that, should you have any concerns about your client's safety or wellbeing, you're welcome to speak with Chiltern's Safeguarding Lead in confidence via safeguarding@chilternmusictherapy.co.uk

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Additional Information

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

How did you hear about Chiltern Music Therapy?

Would you like to hear from 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, I confirm that I have either obtained my clients consent or have another lawful basis (such as safeguarding or vital interests) to provide this information. All information will be stored securely, only accessed by authorised staff, and not shared outside Chiltern without appropriate permission (unless required by law or for safeguarding purposes). Data protection rights apply, including the right to request access, correction, or deletion, by contacting the Chiltern Office. Full details are in Chiltern’s Privacy Policy.

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Thank you for completing a referral

Your therapist will be in touch shortly. 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.

If you need any other information or assitance please don't hesitate to contact us.

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