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REFERRAL FORM
BCAT offers Art, Drama, Dance Movement and Music Therapy in group or 1:1 session. Please print out and complete this form and return it to the centre before the commencement of the initial assessment session. The information you provide will better enable the therapist to assess the Client's needs. Each Client referred should have a separate referral form. All information is confidential. BCAT thanks you for your co-operation.
| Referrer Details: Name: Address: Telephone: |
Position: Relation to Client: |
| Client Details: Name: Address: Telephone: |
Date of Birth: Age: Sex: Ethnicity: |
| Therapy Details: Reason for referral: Which Therapy (if known) is preferred? |
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| Art: | Dance Movement: | Drama: | Music: | ||||
| Is the Client receiving any other therapy
input? If 'YES', please give details: |
YES/NO |
| Other Information: Medical Condition: Mobility Problems: Sensory Impairment: Learning Difficulties: |
| Preferred location for therapy sessions: | ||
| Friends Institute | Midlands Art Centre (Art Therapy Only) | Outreach |
| What day(s) of the week/time(s) of day would be most convenient for the initial assessment? | ||
| Method of Payment: | |
| By Monthly Invoice | By Cash Weekly |
| (If possible, payment
by monthly invoice is preferred by BCAT) Invoice details: Name: Address: Contact: |
Purchase Order (If
relevant) Telephone: |
| Signed | Date |
Thank you for completing this form.
Please return to BCAT at the address on the home page.
| Office use: Date of Assessment: |
Therapist: | Reference No |