Referral Form

Please note that all items marked * must be completed

Client Name

First Name

Last Name

Gender

Date of Birth (DD/MM/YYYY)

Diagnosis

Ethnicity

Other ethnicities (please detail)

Please list additional ethnicities or any that are not listed above.

Languages used at home:

Contact info

Name of parent/ caregiver

First Name

Last Name

Name of other parent/ caregiver

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Mobile phone

Sibling's Names & DOBs:

Key Workers, Starship Paediatric Palliative Care Team

Name of primary contact

First Name

Last Name

Email (Primary contact)

Phone (Primary contact)

Name (Second contact, if applicable)

First Name

Last Name

Email (Second contact)

Phone (Second contact)

Music therapy session info

Best time of day (Sessions are held on Fridays)

Morning

Early Afternoon

After school

Home or Hospital

Home

Hospital

Either

Reason for referral:

Hopes and expectations:

Child and family’s understanding of illness:

Current symptoms/challenges/safety concerns: