HEARTH
The home of Earth Art Therapy
Central Desert Art & Nature Therapies
Date of Referral:
Date of Referral:
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Month
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Day
Year
Date
Referral Source:
Referral Source:
Self-Referral
GP/Physician
Mental Health Professional
School/Educational Service
Community Services
Family Member
Other
Referrer's Name (if applicable):
Organization:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Participant information
Full name:
First Name
Last Name
Preferred name:
Date of Birth:
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Month
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Day
Year
Date
Pronouns:
Emergency contact:
What emotions or experiences are you hoping to process? (Briefly describe what you would like to address)
What are your current experiences?
What are your current experiences?
Stress/burnout
Overwhelm
Racing thoughts
Grief & Sorry Business
Intrusive memories
Heaviness
Emotional unease
Self-doubt
Navigating life Transition
Relationship Difficulties
Neurodiversity
Chronic Illness/Pain
Environmental Distress
Disconnection
Other
What do you hope to gain from our sessions? (What are we working towards)
What do you hope to gain from our sessions? (What are we working towards)
Emotional wellbeing
Stress support
Creative expression
Improved self-awareness
Connection with nature
Intergenerational healing
Personal growth
Improved coping skills
Community connection
Other
Ezmarelda Rose
Art & Eco Therapist
ABN: 38247552002
PH: 0426 427 085
Email: Hearth.therapies@gmail.com
www.hearth-earth-art-therapies.com
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HEARTH
Creativity Community Country
Health & Wellbeing Story
Current Physical Health Conditions:
Current Holistic Health Worries: (physical, mental, emotional, social, environmental, and spiritual well-being)
Current Medications (if any):
Previous Therapy or Counselling Experience: (If yes, please describe)
Risk & Safety
Are you currently experiencing any of the following?
Thoughts of self-harm
Thoughts of suicide
Recent suicide attempt
Risk of harm to others
Current domestic/family violence concerns
Substance use worries
Other
Please provide breif details:
Art Therapy
No prior art experience is needed for Art Therapy to be effective, creativity flows through us all in its own way. Art Therapy is more focused on the process of creating and less about the final outcome, it also draws attention to how different art materials and processes make us think, feel, and respond.
How comfortable are you with creative activities?
Very Comfortable
Somewhat Comfortable
Unsure
Uncomfortable
What art materials or processes are you interested in exploring?
Do you have any sensory needs, or disomfort with any art materials?
Ezmarelda Rose
Art & Eco Therapist
ABN: 38247552002
PH: 0426 427 085
Email: Hearth.therapies@gmail.com
www.hearth-earth-art-therapies.com
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HEARTH
Creativity Community Country
Eco Therapy
Nature-Based Activities of Interest
Nature-Based Activities of Interest
Nature walks
Mindfulness in nature
Gardening
Animal connection
Outdoor art-making
Earth Art / using natural materials
Seasonal reflection practices
Environmental education
Group eco-therapy
Other
Accessibility & Outdoor Participation: Do you have any physical, sensory, medical, or accessibility needs that may affect your participation in outdoor activities?
Allergies or Environmental Sensitivities:
Cultural & Community Considerations
Are there any cultural, spiritual, religious, or community considerations that you would like me to be aware of?
Do you have any cultural practices, communities, country, or family that are important to your wellbeing and support?
Risks, expectations, and benefits
Just like any therapy, you may find yourself in a difficult situation in discussing and expressing your emotions, having uncomfortable feelings resurface, and recalling painful memories. Art Therapy supports healing by moving unresolved emotional energy through the body out into art, where it can inspire reflection, promote growth, and build self-awareness. Eco Therapy brings awareness to the ways in which our health and wellbeing are linked to our relationship with nature, it helps to rekindle a sense of belonging to ourselves, each other, and our enviroment. As an Art Therapist my focus is to explore what emerges through your self-expression, material process, and the engagement you have with your art. Together we can reflect, process your images, and the artwork you create, discovering the insights, and meaning found along the way. As an Eco Therapist my role is to work alongside nature as co-therapist, honouring the active role nature has in providing a restful and restorative foundation to ground people in themselves, and their environment.
Ezmarelda Rose
Art & Eco Therapist
ABN: 38247552002
PH: 0426 427 085
Email: Hearth.therapies@gmail.com
www.hearth-earth-art-therapies.com
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HEARTH
Creativity Community Country
Confidentiality
Hearth respects the privacy and confidentiality of every participant. All information discussed during sessions remains in the therapeutic space, unless there is concern that you are at risk of hurting yourself or someone else. As a duty of care I have mandatory reporting obligations, I would only share information with staff or service providers that are an essential part of your care.
I understand that:
Participation in art and eco-therapy is voluntary
Information provided on this form will be kept confidential, subject to legal and ethical obligations
Outdoor activities may involve natural environmental risks
I have had the opportunity to ask questions regarding services and participation
Name:
Signature:
Date:
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Therapist use only
Initial session date:
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Month
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Year
Date
Appropriateness for Service:
Suitable for Individual Sessions
Suitable for Group Program
Suitable for Eco-Therapy Activities
Further Assessment Required
Referral Elsewhere Recommended
Notes:
Referral Outcome
Accepted
Waitlisted
Referred to Alternative Service
Follow-Up Date:
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Month
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Practitioner Signature:
Date:
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Month
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Day
Year
Date
Ezmarelda Rose
Art & Eco Therapist
ABN: 38247552002
PH: 0426 427 085
Email: Hearth.therapies@gmail.com
www.hearth-earth-art-therapies.com
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