Therapy Referral Form - Corsham School

MUSIC THERAPY REFERRAL FORM

THE CORSHAM SCHOOL

This referral form is for use by staff at The Corsham School only, to refer pupils for music therapy sessions at The Rhythm Practice. Copies will be held confidentially by The Rhythm Practice and shared with Lydia Smith, Deputy Safeguarding Lead at The Corsham School.

Therapy sessions are 50 minutes long, aligned with the school timetable, and take place one-to-one in a private music therapy studio at The Pound Arts Centre, Corsham. A separate parental consent form will be issued for permission regarding pupils walking to and from sessions and for any necessary recordings. Alternative arrangements will be made if consent is not granted.

Sessions incorporate talking, music, and art-based psychotherapy to support pupils’ mental health and emotional wellbeing. They are offered in six-week blocks and may be extended where appropriate, in agreement with the therapist and pupil.

The Rhythm Practice are approved Alternative Providers (UKPRN 10094232) with Wiltshire Council and, as such, adhere to robust and comprehensive health and safety and safe guarding requirements.

Information about our procedures is available on request.

Details of staff member completing the referral

First Name

Last Name

Email

Position at The Corsham School

Relationship with pupil

Information regarding the pupil requiring support

First Name

Last Name

Date of birth

MM

DD

YYYY

Gender identity and pronouns (if specified)

Which of the following areas would you suggest the young person needs help with:

Communication and self-expression – Developing verbal, non-verbal, and emotional communication skills

Emotional well-being and resilience – Managing emotions, coping with stress, and building self-regulation skills

Confidence and self-esteem – Developing a positive self-image and belief in their abilities

Social skills and relationships – Engaging with others, forming friendships, and navigating social situations

Engagement and motivation – Encouraging participation in activities and maintaining focus and interest

Managing behaviour and self-regulation – Understanding emotions, managing impulses, and responding appropriately

Adjusting to change and transitions – Coping with new environments, routines, or significant life changes

Sensory and physical needs – Addressing sensory sensitivities, movement needs, or physical challenges that impact well-being

Safeguarding and emotional safety – Providing a safe and supportive environment for emotional and psychological security

Please give any details

What activities is the young person currently choosing and enjoying outside of school?

Do you have any particular concerns about the young person at the moment? If so, what is particularly difficult?

How do those difficulties affect the life of the young person and those around them?

Does the young person have any conditions or circumstances requiring their music therapist to take special precautions? If so, please give details

Examples include special educational needs, epilepsy, disabilities, safeguarding concerns, or specific risk assessments.

Additional information

Please include any relevant history, such as self-harm, challenging behaviours, triggers, or other factors that may impact the young person’s engagement in music therapy.

Does the young person access any other service, provision or therapeutic support?

If yes, please give details:

Please submit this form by clicking on the button below. All data is stored securely and confidentially in accordance with our data protection policy.