Organisation referral form

Thank you for getting in touch with us about music therapy in your organisation. The form below will ensure we have the right information to move forward with your enquiry - please allow up to 7 business days for a reply.

If you are an organisation making a referral on behalf of a client that would like to receive private individual sessions, please complete the referral form on our website www.smt.nz/referral-form.

We look forward to working with you very soon.

Details of the person completing the form

Key contact information

If different to the above

Funding

Services

To ensure we can provide you with all service options & fees, please select all you are interested in - our day packages can be inclusive of both individual & group sessions - these will be tailored to your needs.

Client information

Please provide us with some more information about those that will receive our services including name (if appropriate), age, gender & diagnosis/medical history.

E.g - John Smith - 58 - male - Parkinson's or child - 8 - female - ASD lvl3, non-verbal.

If you do not know specific information, please give an indication of number of clients and indication of diagnosis/medical history.

E.g - 4 x adults - Intellectual Disablity.

Availability

We will always endeavor to make sure our availability works with yours. However, we are not always able to guarantee this will work. To help us find a time that suits, please let us know below your preferred availability.

Additional information