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Referral Form for Artistic Therapy 
Please complete the following information to submit your referral for therapeutic art sessions with Emma Toy. 
Every person will have a free 20 minute consultation via phone or in person to discuss expectations and needs, ask questions, and to see whether you think artistic therapy is right for you before committing to attend.
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Email *
Name of person being referred for artistic therapy *
Date of birth *
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DD
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Caregiver / Parent Name (if the person being referred is a child/student)
Contact Phone Number 
(Caregiver/Parent Contact number if the person being referred is a child)
Reason for referral 
Hopes and expectations for participating in artistic therapy
Anticipated duration of therapy 
(Please note that there is a minimum commitment of 7 sessions)
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Name, Agency Name, and Contact Details of Referrer (if not self referred)
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