Referral Form

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Referral Form

Victoria Art Therapy

ALL INFORMATION IN THIS FORM IS CONFIDENTIAL AND WILL NOT BE DISCLOSED TO ANY OTHER THIRD PARTY.

ARTS THERAPY REFERRAL FORM

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Victoria art therapy logo and letter head

ALL INFORMATION IN THIS FORM IS CONFIDENTIAL AND WILL NOT BE DISCLOSED TO ANY OTHER THIRD PARTY.

ARTS THERAPY REFERRAL FORM

 

Gender

About the Client

Please fill out the details below

Name
Does the client require an outreach service?
Address
Emergency contact
NDIS FUNDED
Management type

Agency Information

Name of person submitting referral
Support co-ordinator name

Reason for referral

 

NDIS goals as noted in the plan:

 

Goals for art therapy:

 

Is the client medication compliant? YES/NO
Is there a ʻcrisis planʼ in place?
Please tick if the following issues that apply to this client: (Risk assessment)
Frequency of Services
Type of session
Does the client have a court appointed guardian?
Name of guardian
Is the client aware of this referral?
Is the client (or family) managed by a ʻcare team’?

Client Consent Form

Services

As part of providing, you with a creative arts therapy approach, Victoria Art Therapy will need to collect and record personal information about you that is relevant to your current situation. This information is a necessary part of the assessment process as well as assisting Victoria Art Therapy to choose the most applicable arts therapy interventions to meet your goals. (This includes recording video or photo images of the artwork you create in or out of the therapeutic sessions). Recording images are part of an arts therapist’s case note process and can also be used for the purposes of professional supervision which is in line with maintaining professional registration and membership with our professional association.

Access

You may access the material record in your file upon request, subject to the exception in the National Privacy Principle (6).

Confidentiality

All personal information gathered by me during the arts therapy service will remain strictly confidential and secure except when:

  1. It is subpoenaed by a court, or
  2. Failure to disclose the information would place you or another person at risk, or
  3. Your prior approval has been obtained to:

(a) provide a written report to another professional or agency e.g., a GP, a lawyer, members of a Care Team, a court appointed guardian, or

(b) discuss material with another person e.g., a parent, an employer, primary psychologist, social worker, case manager or treating health professional.

Cancellation policy

If, for some reason you are unable to attend the scheduled appointment time, please contact me at least

24 hours’ notice, otherwise you will be charged the cost for the full session. NDIS participants are charged 90% of the scheduled fee.

Charter for clients of counsellors

All arts therapist that provide therapeutic services at Victoria Art Therapy are registered with the Australia, New Zealand and Asia Creative Arts Therapy Association (ANZACATA). As members of this peak body of creative arts therapies we adhere to strict professional and ethical guidelines of this Association. For more information www.anazacata.org

Please read this information to the client

I understand that I will only have to pay for these services if I am self-managed or I am a private client. I do not have to pay for these services, if they form part of my funding package (or paid by another agency). The arts therapist may want to contact some of the services involved in my case plan so as to provide me with a professional, enjoyable and quality arts therapy service tailored to my needs & interests. I give consent to Madeleine Chelini (Arts Therapist@ VAT) to contact relevant health care services.
I have read or it has been explained to me by (parent, guardian or agency worker)

I understand and hereby consent to the terms and conditions as outlined above. I give my consent to having still or moving images taken of my artwork as part of the conditions of undertaking arts therapy at Victoria Art Therapy. I understand that my name and their identity will not be disclosed in relation to these images/ videos.

Clear Signature