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Music Therapy Clinical Referral Form

Fill in the form below with your requirements and we'll get back to you as soon as we can

As part of our work and to help us understand the needs of each client it is important for us to have contact with other professionals involved in the client’s care, e.g. Psychiatrist, Speech & Language Therapist, Occupational Therapist, Physiotherapist:

Client Details

Inscape Therapies Consent for Recording

I would be grateful if you could answer the following three questions

(Please circle YES or NO).


These are standard questions for all new clients. Any decision regarding the recording of material will not affect the undertaking of the music therapy itself.

My approach to Music Therapy is creative, with music improvised to meet each person’s individual needs – It is therefore standard practice for me to use audio and/or video to record the sessions for my professional use, in order to establish progression a
Yes
No
In addition to this I occasionally use video/audio material for other purposes: Do you agree to video/audio material from clinical sessions being used for professional, educational and/or informative purposes? (Confidentiality is respected, and only first
Yes
No
Would you be willing for me to use material on the above-named client in order to publicise Music Therapy in Scotland?
Yes
No
Would you be willing for me to use material on the above-named client in order to publicise Music Therapy in Scotland?
Yes
No

Please sign and date the foot of the form. If you have any difficulties or queries about any of the above, please contact me on: 07912314469

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