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Name *

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Last

Preferred pronouns

We are an inclusive space. All identities are valued - we just want to make sure that we get things right for you!

Date of birth *

Email *

Address *

Daytime telephone number *

Emergency contact

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Last

Emergency contact email

Emergency contact telephone number

What are your strengths and interests?

What music do you enjoy?

Do you play an instrument? If so please give details.

Please note you do not need previous experience playing an instrument to take part in music therapy.

What is the reason for referral? (This might be a formal diagnosis or a description of challenges your child experiences.) Please include details of any specific medical needs. *

Do you or anyone in your household have health needs which place them in a high risk category for COVID-19? *

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No
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