Therapeutic Song Writing (Referral Form)

THERAPEUTIC SONGWRITING

REFERRAL FORM FOR HEALTH CARE PROFESSIONALS

This is an opportunity for an individual to work with a fully qualified music therapist at The Rhythm Practice to write and record their own original song. The individual does not need any previous experience or ‘musical abilities’ and will be supported throughout the process by a highly skilled therapist who specialises in therapeutic songwriting.

The project is overseen and funded by The Songwriting Organisation UK CIC.

Sessions are delivered by The Rhythm Practice and take place at The Pound Arts Centre, Corsham, Wiltshire.

This programme includes:

6hrs of private, face to face time with a fully qualified music therapist at The Rhythm Practice
Private use of a fully equipped music studio and instruments
A recording of the song created during sessions

Please complete ALL SECTIONS of the referral form below:

DETAILS OF PERSON COMPLETING THE FORM

First Name

Last Name

Job Title

Organisation

Phone

(###)

###

####

Email

Relationship to client

CLIENT DETAILS

First Name

Last Name

Email

Phone

(###)

###

####

Date of birth

MM

DD

YYYY

Gender identity and pronouns (if specified)

Reason for referral

Are there any medical conditions the therapist should be aware of?

GP DETAILS

Name of GP

Surgery address

Questionnaire

Before starting and after completing the programme, The Songwriting Organisation UK will ask you to complete a confidential and anonymised questionnaire relating to your well-being and experience with the songwriting programme. This data is vital to help secure future funding. Are you happy to complete this?

Yes

No

Please submit this form by clicking on the button below.

All data is stored securely and confidentially by The Rhythm Practice and in accordance with our data protection policy, available on request.