Name*

Address*

Phone

Mobile Phone*

Email Address*

Date of Birth*

Pronouns Pronouns he/him/his she/her/hers they/them/theirs ze/hir/hirs other

School attending (if applicable)

NDIS Review Date (if applicable)

NDIS No (if applicable)

How Is Your NDIS Plan Managed? How Is Your NDIS Plan Managed? Self-Managed - You manage your NDIS funding; we invoice you directly Plan-Managed - You have engaged a Plan Manager who pays your providers for you; we invoice them directly NDIA-Managed - The NDIA pays your providers on your behalf; we claim through the portal

If Plan Managed, please provide name and email address of plan manager

Referral From Referral From Self referral I am a CoS/Support Worker/Other completing this referral on behalf of my client (please provide your name and email address)

Referring CoS/Support Worker/Other Contact Information

Languages spoken

How did you hear about/find Newcastle Music Therapy?

Availability For Sessions Days/Times:

Frequency of Sessions* Frequency of Sessions* Weekly Fortnightly Other

Reason for Referral* (Why do you want to have art therapy? What are you hoping to get out of it? What issues are there that you would like art therapy to address?)*

NDIS goals (if applicable)

Medical History (incl diagnosis)

Current Medication

Other Interventions/Therapies (e.g. speech pathologist, psychologist)

Art making history - Interests, hobbies and passions

Art materials you like and dislike

Sensitivities to sound; light, texture or touch

Social history: any significant life events (both highlights and difficulties), younger life and current life circumstances impacting mood, current living circumstances/home environment

How is it for you stepping up and down stairs WITH a railing/wall?* How is it for you stepping up and down stairs WITH a railing/wall?* Easy Need Assistance Not Possible

Other Relevant Information

Date of Referral