Referral form

Before completing this form please read our eligibility criteria.

All form fields must be completed.

Client details

Name of child

Date of birth

Referrer details

Name of referrer

Job role

Contact number

Email address

Referral organisation

Parent/carer details

Parent/carer name

Contact number

Please tick to confirm that parental permission has been sought.

Therapeutic need

Please explain why you feel this child would benefit from play therapy.

Eligibility questions

Is the child eligible to receive Free School Meals?

No Yes

Is the child currently being supported by Children's Integrated Services?

No Yes

Does the child receive High Needs Funding?

No Yes

Is the child entitled to support from Virtual Schools Kent or Post Adoption Services?

No Yes

Does the child live within the Canterbury District (as defined by KCC district boundaries)?

No Yes

Payment contribution

We subsidise the cost of therapy to ensure it is affordable and benefits those who could not otherwise afford the support. Please tick to confirm that you are able and willing to pay £25 per session (number of sessions will be agreed as part of clinical assessment although we ask for a minimum commitment of 12 sessions).

Confidential space

We bring the therapeutic support to children in schools to minimise the disruption to their learning and to support children in feeling comfortable in their surroundings. Please tick to confirm you can provide a confidential space suitable for play and creative arts therapy.

Data management

Please tick to confirm you have read and understood our privacy policy.