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Join
Calendar
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Who We Are
About Challenge
Who We Are
What We Do
Leuk the Duck
Membership
Become a Challenge Member
About Membership
Challenge Membership Form
Sibling Membership Form
Member Stories
Our Programs
Emotional Support
Art Therapy
Massage Therapy
Music Therapy
Parent Support
Practical Support
The Challenge Family Centre
Holiday Accommodation
Hospital Support
Scholarships and Trusts
Social Support
Activities and Outings
Camps
Playgroup
Get Involved
Challenge Fundraising Campaigns
#DoingItForJarrod
A Day in May
KTM Ride4Kids
Tackling Childhood Cancer
Challenge Fundraising Gala Events
Challenge Ball
Diamonds Are A Girl’s Best Friend
Robert Allenby Golf Day and Gala Dinner
Community Fundraising
Biggest Aussie Pie Night
Golf Days
Leuk the Duck™ Merchandise
Lace up for Challenge
Volunteer
Volunteer with Challenge
Donate
News
Shop
Contact Us
Donate
Art Therapy Referral Form
Art Therapy Referral
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
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
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
*
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