Please complete this form as fully as possible. It will allow us to find a therapist who will best fit with the child/young person and family. We will arrange a short telephone conversation with you once we have received the form to discuss potential therapists and time scales. We will get back to you within 7 days of receipt of the referral form.
Contact Details
Please note: Once funding is approved information packs are sent to parents/guardians and school (if appropriate). The aim is to inform them about Chroma and the Creative Arts Therapies in preparation for therapy to then begin. For this to happen an email or physical address is needed.
Child’s Name
Date of Birth
Parent/guardian name
Home Address
Home Telephone
Mobile
Email
Permission to contact parent/ guardian at referral stage
Y/N
Permission to contact above once funding is approved
Yes
Agreement to complete BAC
Yes/No
Permission to share BAC scores with LA/RAA
Yes/No
Permission to share BAC scores with ASF
Yes/No
School Name – if therapy is to take place at school
Contact Name
Position
School Address
Telephone Number
Email Address
Any other professional working with the child (i.e. Educational Psychologist) name and contact details
Any formalised assessments done?
Copies requested for therapy programme planning.
Any risk factors for 1:1 work?
(Behavioural/ safeguarding/history of allegations?)None identified
Diversity information on child to whom the referral applies A
Ethnicity:
Gender:
Any SEN?
Accessibility Issues?(ie. physical/sensory/ English not first language)
N/A
Health needs
N/A
Diagnosis?
N/A
Medication?
N/A
Is there CP/CIN?
Other referrals in process?
Social workers’ / Family support worker’s detailsA
Name
Contact Details
Name for invoice/ purchase order/ contracts
Contact Details
Details of therapyA
Location of therapy if school is not suitable
If therapy is to be held in a community venue, has discussion been held about potential support and safety around this?
Any specific therapy requirements?
modality (music/drama/art/any)‘Creative’in school/after school/ community locationNot specifiedany specific therapist requests? NoIndividual sessions/joint sessions?individualWould family travel up to half an hour for sessions if required?
Anticipated outcomes of a referral to creative arts therapy (music therapy, dramatherapy or art therapy) Please highlight 3 AIMS for therapy from the following options
Support the young person’s sense of self esteem and confidence.Enable the young person’s ability to express, process and regulate emotion.Offer the young person coping strategies when experiencing challenges and difficult emotions.Support the young person’s relationships with peers, family and helping adults.Provide space for the young person to explore their sense of self and identity.Explore the impact of early attachment on young person’s behaviour and feelings.Improve the young person’s parents/carers ability to create a trauma informed environment.Enable the young person to express themselves and communicate using creative, non-verbal therapy.Support the young person through a period of change/transition, for example, changing schools.Support the young person to cope with issues concerning bereavement and/or loss
Presenting behaviours leading to referral for therapy including strengths and needs of child/family and impact of history on current family life.
Is child aware of the referral?
Chroma works with the family, even when their child is being seen individually. Please let us know about the adoptive family culture.Please complete this as fully as possible. It will enable us to be inclusive and aware of the family’s needs.
Parent/Guardian ethnicity and cultural background
Health concerns and/or disabilities
Socio economic status
Religion
Gender / Sexual Orientation
Any other relevant information e.g. Age
Adoptive/Placement family details – history of adoption/placement, siblings, family activities and interests
Please attach the assessment of need. If Assessment of need not attached, please do fill in the following sections.
Background
Birth family history including reasons for removal
Foster care experience
Any previous Therapy Interventions
Feedback
Other information pertienant to referral
Completed By
Date
For Admin Use Only
Brief Assessment Checklist Score
DATE COMPLETED:
Contact Details for Post- Therapy Brief Assessment Checklist score
Aims for Therapy as identified at referral stage (3 only)
Support the young person’s sense of self esteem and confidence.Enable the young person’s ability to express, process and regulate emotion.Offer the young person coping strategies when experiencing challenges and difficult emotions.Support the young person’s relationships with peers, family and helping adults.Provide space for the young person to explore their sense of self and identity.Explore the impact of early attachment on young person’s behaviour and feelings.Improve the young person’s parents/carers ability to create a trauma informed environment.Assess how using creative, non-verbal therapy enables the young person to express themselves.
