Referral Form: Carolina Music Therapy
Please complete the following questions for music therapy referral.
Your answers are confidential and will solely be used in treatment planning and service delivery.
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Email *
Your name: *
Your phone number: *
Your workplace or organization if applicable (community partner, healthcare agency, school, etc)
May we share with the client that you have referred them for music therapy services? *
Name of potential music therapy client: *
Parent/guardian or case worker of client (if applicable): *
Phone number of client (or parent/guardian, case worker if applicable) *
Which needs led you to refer this client? *
Required
What are a few of the client's strengths? *
Does the client have difficulty with mobility or use assistive devices for mobility? *
What is the primary language used by the client? *
What are some things that bring this client joy? *
How did you hear about us? *
Required
Thank you! We look forward to learning how we can serve this client.
If you have any additional questions, concerns or comments, please contact us via email (director@carolinamusictherapy.com) or by phone (864-680-6985).
A copy of your responses will be emailed to the address you provided.
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