Outreach Referral Form

Please fill out the details below to refer participants for group music therapy services. We’d appreciate if this referral form was completed at least one week prior to the programme commencing. Please fill out one form per group or class (the recommended group size is 5-6 clients per session).

This information will be used by our Registered Music Therapists to help plan their sessions and will be kept confidential, in line with the Privacy Act. Get in touch with us at info@rmtc.org.nz or 09 360 0889 if you have any questions regarding this referral form.

Please note that all items marked * must be completed.

Region receiving music therapy services

Auckland

Hawke's Bay

Northland - Whangarei & Kaipara

Northland - Far North

Other

Name of current Music Therapist (if known)

School/Organisation

Class/Group

Primary Contact

First Name

Last Name

What would you like this group to achieve through music therapy?

Participant Details

Name

First Name

Last Name

Date of Birth

YYYY

Ethnicity

Diagnosis

Factors therapist should be aware of

Name

First Name

Last Name

Date of Birth

YYYY

Ethnicity

Diagnosis

Factors therapist should be aware of

Name

First Name

Last Name

Date of Birth

YYYY

Ethnicity

Diagnosis

Factors therapist should be aware of

Name

First Name

Last Name

Date of Birth

YYYY

Ethnicity

Diagnosis

Factors therapist should be aware of

Name

First Name

Last Name

Date of Birth

YYYY

Ethnicity

Diagnosis

Factors therapist should be aware of

Name

First Name

Last Name

Date of Birth

YYYY

Ethnicity

Diagnosis

Factors therapist should be aware of

Name

First Name

Last Name

Date of Birth

YYYY

Ethnicity

Diagnosis

Factors therapist should be aware of

Name

First Name

Last Name

Date of Birth

YYYY

Ethnicity

Diagnosis

Factors therapist should be aware of

Name

First Name

Last Name

Date of Birth

YYYY

Ethnicity

Diagnosis

Factors therapist should be aware of

Name

First Name

Last Name

Date of Birth

YYYY

Ethnicity

Diagnosis

Factors therapist should be aware of