Referral Form
Thank you for your interest in music therapy. Please complete this form so we can understand your needs and determine suitability. All information is treated confidentially.
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Contact details
Your Name (parent, referrer)  *
Email address *
Phone number *
Preferred contact method *
Required
Client information
Client Name *
Date of Birth  *
MM
/
DD
/
YYYY
Address
Preferred space for therapy session 
Background
What brings you to music therapy?
Diagnosis (optional)
Client's background information
Clients preferred way to communicate? 
Current supports (OT, SLT, psychologist, etc.)
Type of music therapy session
Goals for music therapy
Practical Information 
Funding type  *
Required
Preferred days/times *
Required
How did you hear about Music for life? 
Music for life "terms and conditions"
Music for life terms and conditions
Privacy & Consent *
Required
Privacy Notice

Your information will be stored securely and used solely for the purpose of responding to this referral and providing music therapy services. It will not be shared without your consent unless required by law.

In New Zealand, this aligns with the Privacy Act 2020.

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