Music Therapy Referral Form
If you wish to receive a paper copy, or need more information before filling in this form please email info@smt.nz or look at the website for more details. Please note that as an example of prices below: Initial sessions start from $160+gst (one off cost for new clients) Individual sessions start from $100+gst per session Group sessions start from $350+gst per term Once the referral from has been received and processed, you will be added to our waitlist and we will be in touch with possible times for the initial session, our Health and Safety Policy, our Cancellation Policy and our Term Dates. We may also be in touch to discuss the referral and possible schedule further, this will be over email and or phone, so please fill in these details with as much detail as you can. This referral form can be completed by yourself, it does not need to be filled in by a medical professional.
Details of person being referred (client)
Full Name
Date of birth
Contact details (Email, Phone & Address if relevant)
Gender
Ethnicity/Cultural/Spirituality Information
Key Contact/Primary Carer Details
A key contact/Primary Carer is the main person to contact.
Full name
Relationship to client
Email
Phone Number
Other Key Contact/Primary Carer Details
Health, Safety & Wellbeing
Diagnosis/Medical History?
What is the clients preferred way of communicating?
Any relevant health concerns SMT needs to be aware of? (Physical/Mental Health/HIV/HEP/Medical (Epilepsy/Diabetes)/Communication Impairments/Swallowing/Allergies)
Does this client present with any behavioural concerns? (Please provide us with the risk assessment and read the SMT behavioural policy provided)
Music Therapy Goals
Reasons for referral?
Physical
Communication
Social/Emotional
Cognitive
Hopes & Expectations for Music Therapy?
What type of service are you requesting?
Individual Sessions
Group Sessions
Mixed (Group & Individual sessions)
Unsure
Availability
We will always endeavor to make sure our availability works with yours. However, we are not always able to guarantee this will work. To help us find a time that suits, please let us know below your preferred availability.
Preferred Time - Please select 2 or more.
Morning
Afternoon
Anytime of the day
Outside of school hours - after 3pm
Please let us know days/time that are NOT suitable due to prior commitments.
Account contact details
If you would like to read more about the funding updates for 2024, please go to our funding update page on our website to find out more.
I would like to receive a copy of the SMT funding document
Who will be paying for these sessions?
Private Paying Client
Funded Client
Who is your funding provider?
Funder
ACC
Allenvale
Brackenridge
Cancer Society
Equitas
Enabling Good Lives (EGL)
Florence Nightingale
High & Complex Needs (HCN)
Hōhepa
Laura Ferguson (Rehabilitation)
Life Links
Manawanui
Ministry of Education
Oranga Tamariki
Other
Funded client only
Yes, I have funding approved & can commence sessions
No, I do not have funding approved & may require a quote before sessions can commence
No, I do not have funding approved but happy to commence sessions & pay privately until approved
Key Accounts Contact Name
Key Accounts Contact Email address? (Invoices will be sent to this email address)
Phone Number
Other Key Accounts Contact Details (this includes any additional email address for the invoices to be sent to)
Supporting Agency Details
(If applicable)
Key Support Agency Contact Name & position
Key Support Agency Contact Email
Key Support Agency Contact Phone Number
Other Key Support Agency Contacts
Additional information
Who is completing this form and what is your relationship with the client?
Your email address?
Your phone number?
Is there anything else we need to know?
How did you find out about us?
Select from
Referral
Word of mouth
Facebook
Google
Other
Your Signature
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