Refer a Child/Young Person

  • This form should be used to refer a child or young person aged under 18 for Music Therapy. All information given will be treated as confidential.

  • Child's Details

  • Date Format: DD slash MM slash YYYY
  • Parent/Guardian Details

  • Alternative Referrer Details

    This section need only be completed when the Referrer is NOT the Parent/Guardian.

  • School/Nursery Details

  • Location/Availability for Therapy

  • More Information on the Referred Child

  • Invoicing

  • Your Consent

    RMT Privacy Notice (opens in a new tab)
  • Date Format: DD slash MM slash YYYY

Terms and Conditions

Please ensure you read the Terms and Conditions before completing the referral form.