Refer Yourself - Richmond Music Trust

Use this form if you are 18 or over and wish to refer yourself for Music Therapy.

Your Details
Name*
First Last
Date of Birth*
Date Format: DD slash MM slash YYYY
Languages Spoken*
Phone*
Email*
Address*
Street Address Address Line 2 City Post code
GP Details
GP's Name*
First Last
Practice Phone Number*
GP Practice Name/Address*
Street Address Address Line 2 City Post code
Other Professionals
Please give name(s) /contact number(s) of any professionals involved with you
More About You
Why would you like to refer yourself for Music Therapy?
Do you have, or have you ever had, mental health issues?*
- Yes
- No
If yes, please give more details, including diagnosis (if known) and medication (if any)
Do you receive any other form of therapy?*
- Yes
- No
If yes, please list below
Please use this space to list any other information or concerns
Your Consent
I confirm that I have read/agree to the Terms and Conditions on this page and that I consent to RMT using my personal information as outlined in the RMT Privacy Notice.*
- Yes
- No
RMT Privacy Notice (opens in a new tab)
Your Name*
First Last
Today's Date*
Date Format: MM slash DD slash YYYY

Terms & Conditions

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