Play Therapy Referral form.
For Education / Social Work / Family Support / Health Professionals
Your name
*
First Name
Last Name
Your profession / relationship with child
*
Teacher/Social Worker/Family Support/GP etc
Your work place
*
Name of organisation and address
Phone Number
Format: (000) 000-0000.
Email
*
Child's name
*
First Name
Last Name
Child's date of birth
*
Child's home address:
*
Street Address
Street Address Line 2
Town
County
Postcode
Who lives with the child?
Include names and details of their relationship to the child.
Who currently has Parental Responsibility?
Provide name and contact details
Child's current school address
Name of school
Address
Town
County
Postcode
Child's current academic level(s) if known
Are they meeting expected targets? if not what are the possible reasons for this?
Are there any other agencies involved with this child and family?
*
Please give details of all other agencies
Planned location for Play Therapy sessions to take place?
*
Sessions MUST take place at the same time and place each week unless there are exceptional circumstances.
Main reason for referral (child's current difficulties)
*
Please give details
What impact do these difficulties have on the child and others?
*
Please give details
Are there any predisposing or perpetuating factors?
*
For example: Parental mental health, addiction etc. Child diagnostic pathways/diagnosis. Traumatic events. Please give relevant details.
What are the child's strengths, skills and interests?
*
Please give details
What are your hoped for outcomes following Play Therapy? For example: appropriate expression of anger, processing of difficult events, increased self confidence, improved attendance at school etc
*
Thank you for your referral to Play Therapy Devon. I will contact you shortly with my availability and arrange a time to discuss your referral further. Please note the individual(s)holding Parental Responsibility must sign consent before therapy can take place.
Please use the box above for any other comments.
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