Art Therapy Referral Form

Name of child*
First Last
Please note, Art Therapy is available to children aged 4 years or above.
If your child is below this age, please contact Challenge on 03 9329 8474 to discuss what services we can provide.
Date of Birth*
DD slash MM slash YYYY
Diagnosis*
Date of Diagnosis*

Day
Month
Year
Parent/Carer*
Full Name
Phone*
Address*
Street Address Address Line 2 Suburb State Post Code
Reason for Referral*
Has the child participated in Art Therapy previously?*
- Yes
- No
Where did the child participate in Art Therapy previously?*
Name of Therapist
How long/number of sessions?*
Any other information that would be useful to know?
Name of person making referral*
Full Name
Date of Referral
DD slash MM slash YYYY
Relationship to Child*
Contact Details*
Parent/Guardian Signature*