Initial Therapy Enquiry

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Is this an enquiry on behalf of:

An individual or their parent/carer

A school (any phase or type)

Another organisation

Other (please specify):

This is required

Please enter school organisation information

Name of Setting/Organisation

Telephone Number

Email Address

Postal Address

Please provide contact information:

Full name of Contact Person

Relationship to Client

Job Role

Contact Phone Number

Contact Email

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):

This is required

Please provide details of the client being referred:

First name

Surname

Date of Birth

School Year Group (if appropriate)

Is there a preference of therapy type for the referral?

Dance

Drama

Music

No preference

Does the client have an EHCP?

yes

EHCP application in process

Other (please specify):

This is required

Has the client received therapy previously?

yes

Not known

If 'yes', please give details

This is required

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

Educational Psychologist

Occupational Therapist

Physiotherapist

Social Worker

Speech and Language Therapist

None

Other (please specify):

This is required

Funding available or in place already from:

school

parent

looked after child

EHCP

START

no funding

Other (please specify):

This is required

Initial Therapy Enquiry

Is this an enquiry on behalf of:

Please enter school organisation information

Please provide contact information:

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

Please provide details of the client being referred:

Reasons for referral (add comments if needed below)

Is there a preference of therapy type for the referral?

Does the client have an EHCP?

Has the client received therapy previously?

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

Funding available or in place already from:

Further Information you wish to share with us

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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Is this an enquiry on behalf of:

Please enter school organisation information

Please provide contact information:

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

Please provide details of the client being referred:

Reasons for referral (add comments if needed below)

Is there a preference of therapy type for the referral?

Does the client have an EHCP?

Has the client received therapy previously?

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

Funding available or in place already from:

Further Information you wish to share with us

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: