Momentum Childrens' Charity - Richmond Music Trust

This form should be used to refer a child (aged under 18) for Music Therapy. All information given will be treated as confidential.

Email address to be used as first point of contact with regard to this referral*

Child's Details

Name of Child*

First Last

Date of Birth*

Home Languages*

Home Address including postcode*

Street Address Address Line 2 City Post Code

Is the Parent/Guardian the referrer?*

Parent/Guardian Name*

First Last

Parent/Guardian Email*

Parent/Guardian Phone*

Home Address (where different from child's address)

Street Address Address Line 2 City Post Code

I would prefer to be contacted by*

Referred Child's sibling(s) and Date(s) of Birth

School/Nursery Name

School/Nursery Phone

School/Nursery Email

Keyperson Name

How would you like to access Music Therapy?

When are you available for sessions to take place?

Please use this box to give exact time frames which suit you, e.g. Mon after 4pm

Your reason(s) for referring*

Referred Child's Diagnosis

Referred Child's Medications

Referred Child's Hospital

Referred Child's Family Support Worker

Areas of special caution, i.e. high infection risk

Other therapies received

I confirm that I consent to RMT using the personal information provided as outlined in the RMT Privacy Notice.*

RMT Privacy Notice (opens in a new tab)

Your Name*

First Last

Today's Date*