Referral Form
Helium Arts’ Children’s Creative Health Programme

STEP 1: Sign up by filling in this form. 
STEP 2: We’ll get in touch to say ‘hello’ and make sure that Helium Arts is the right fit.
STEP 3: Once eligibility is confirmed, you can sign up to one of our creative programmes.*

* Our creative workshops are not suitable for children with intellectual disability, profound additional needs, or severe mental health needs. 

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Hospital Name. Please select the hospital your child attends. If your hospital is not listed, please provide the name of the hospital your child attends or is closest to you. *
Required
Referral Type: *
Required
If staff referral, please provide your contact details including: 1. Name, 2. Position, 3. Organisation, 4. Email Address, 5. Telephone Number.
If self referral, please provide contact details of your child's patient support group liaison, consultant or key healthcare worker including 1. Name, 2. Position, 3. Organisation, 4. Email Address, 5. Telephone Number.                                                                                            

We ask this question, so we can better support your child through linking with their key healthcare worker.
Parent/Guardian Name: *
Child's Name: *
Child’s Date of Birth (day/month/year) *
What is your child's gender? *
Parent/Guardian Email Address: *
Parent/Guardian Telephone Number.: *
Second Telephone Number: Emergency Contact: *
Postal Address: *
County *
Eircode: *
Child's Medical Condition *
Will your child be bringing medication to Helium's art workshops? If yes, please advise on medication type below. (Helium Arts provides a  medic in the workshop room.) *
Does your child have any allergies? If yes, please note these below. *
Does your child have any additional needs we need to be aware of? *
Please include details below of additional needs including access requirements *
My child likes... (please tick yes or no for each option below) *
Yes
No
messy play (painting, slime, clay)
to move alot
quieter environments
My child....  (please tick yes or no for each option below) *
Yes
No
has strong fine motor skills
has good social skills
is verbal
is non-verbal
How did you find out about Helium Arts service? *
Required
Optional Newsletter Sign-up
Helium Arts is the national children’s arts and health charity (www.helium.ie). We would love to keep in touch to tell you about what’s happening with our projects and the young people and artists with whom we work as well as details of our events, fundraising activities and other good news! By ticking the box below you are agreeing to be contacted occasionally via email. If you agree to be contacted, you can opt out of receiving updates from us at any time.
Please choose one option. *
Confidentiality and Data Protection    Please tick below that you agree to the following statements:                                                     *
Required
Please note - completing this form does not constitute eligibility to take pare in Helium Arts' programmes. Our Family Liaison will be in touch to assess if the programme is the right for your child. 
Signing Date *
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Is there any additional information you would like to share?
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