Initial Therapy Enquiry

1. Is this an enquiry on behalf of: *

An individual or their parent/carer
A school (any phase or type)
Another organisation
Other (please specify):

2. Please enter school organisation information *

Name of Setting/Organisation	*
Telephone Number	*
Email Address	*
Postal Address	*

3. Please provide contact information: *

Full name of Contact Person	*
Relationship to Client	*
Job Role	*
Contact Phone Number	*
Contact Email	*

4. Is this a request for delivery for an identified client or a general enquiry about potential provision? *

Identified Client requiring delivery
General enquiry regarding wellbeing or therapy provision
Other (please specify):

5. Please provide details of the client being referred: *

First name	*
Surname	*
Date of Birth	*
School Year Group (if appropriate)	*

6. Reasons for referral (add comments if needed below) *

Comment:

7. Is there a preference of therapy type for the referral? *

Dance
Drama
Music
No preference

8. Does the client have an EHCP? *

yes
no
EHCP application in process
Other (please specify):

9. Has the client received therapy previously? *

yes
no
Not known
If 'yes', please give details

10. Are there other professionals involved currently? (eg Speech and Language, Physio, Occupational Therapy, Educational Psychologist, social worker) *

11. Funding available or in place already from: *

12. Further Information you wish to share with us *

13. As part of this triage process, one of our senior therapists will follow up via phone or email: Please state best time or day for contact:

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