Referral Form - Someone Else

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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 (optional)

Client's Telephone number (optional)

Client's Date of Birth

How would you like us to contact your client?

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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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Please let know how you or your client will be paying for sessions. If funding is an issue, please do let us know as we may be able to support your client to access our services through our subsidy programme.

If applicable, how much can you or your client contribute?

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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?

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

Referrer

Yes

No

Client

Yes

No

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