Music Matters Grant - USA
The RCD Foundation are currently trialing a pilot of the Music Matters Program in the state of Wisconsin, USA. This was the home state of the Dawes family when they lived in America. Based on the success of this initial trial, we hope to expand the program to other states in the future. For now, we are only able to accept referrals from within Wisconsin.
Recipients Name
*
First Name
Last Name
Diagnosis and date of diagnosis
*
Recipient's Date of Birth
*
-
Month
-
Day
Year
Date
Name of Parent/Carer
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Reason for Referral
*
Has the recipient ever engaged in music therapy?
*
Yes
No
If Yes, where?
Other relevant information
Treating hospital
*
Hospital clinician contact name
*
(e.g, consultant, CNC, SW)
Hospital clinician email address
*
Name of person making referral
*
First Name
Last Name
Relationship to recipient
*
Contact details
*
Verbal consent has been made by recipient/recipient's family for this referral
*
Yes
No
Family consent to be contacted by the RCD Foundation
*
Yes
No
Submit
Should be Empty: