Nurturing Steps Play Therapy Referral Form

Nurturing Steps Play Therapy

Tel: 089-958 1575 Email: nurturingsteps@outlook.com
Play Therapy Referral Form

Please Note: Submitting this form does not guarantee a place in play therapy. You will be contacted once the referral is received.
1. Child's Information
Child's Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Age

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Address
2. Parents Information
Parent/ Guardian 1
Name
Contact No
Format: (000) 000-0000.
Email
example@example.com
Parent/ Guardian 2
Name
Contact No
Format: (000) 000-0000.
Email
example@example.com
3. Medical Information
Name of Child's GP
GP Contact Number
Practice Address
4. School Information
Name of Current School
School Address
Current Class
5. Reasons for Referral
Please describe your reasons for wishing to access Play Therapy. What are your current concerns for your child?
How long have you had these concerns?
Are there any other relevant issues?
What concerns or difficulties are you currently experiencing with your child? Please tick all that apply.

Other
When are these difficulties most noticeable?

Other
In seeking intervention, what do you hope for?
Has your child been diagnosed with, or are they awaiting any assessment for neurodivergence (e.g. autism, ADHD, dyspraxia, dyslexia, etc).
If not, have you any concerns of neurodivergence? If yes, please describe.
Timeline of Events

Please list all significant events in your child’s life in chronological order, from pregnancy to the present, including developmental milestones and important experiences (e.g., starting crèche or school, birth of siblings, etc.). Please also include any significant events in the lives of parents or family members during this time.
Timeline
Please describe your child's interests and strengths.
Name of person completing this form
Relationship to child
Date of Referral

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
How did you hear about my play therapy practice?

Other
Consent and Signature
I confirm that the information provided is accurate. I understand that this form is for referral purposes only and does not guarantee immediate placement or availability.
Note: Both legal guardians/parents must sign this form unless a court order/ birth certificate is attached to declare sole guardianship.
Parent/Guardian 1
Signature:
Print name:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian 2
Signature:
Print name:
Date:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Nurturing Steps Play Therapy

Play Therapy Referral Form

1. Child's Information

2. Parents Information

3. Medical Information

4. School Information

5. Reasons for Referral

Timeline of Events

Consent and Signature

Parent/Guardian 1

Parent/Guardian 2