Referral Form Play Therapy .pdf

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Original filename: Referral Form Play Therapy.pdf
Title: Microsoft Word - Referral Form Play Therapy.doc
Author: James

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Play Be Therapy Referral Form
Referrer’s Name:
Relationship to Child (e.g, Keyworker)
Name of Setting / School:
Address of setting:
Phone :
Email:

Child’s Name:
Date of birth:
Parents/carers Name/s (If different from above):
Home Address:
Home Phone:
Mobile:
Email:

Is there anyone else who is currently actively involved with the child who
needs to be aware of the referral? (e.g Health Visitor, Social Services). If so,
Please give their name and contact details below:

Who lives with the child at home? (please include brothers, sisters, other
relatives, pets):

Any other significant adults/children in the child’s life:

Details of family history & recent events:

What are the child’s strengths?

Child’s presenting difficulties:

Signed Parent/ carer _____________________ Date __________________
Signed Referring party ___________________ Date _________________
Received By _______________________ Date ________________


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