Referral Form - Building Rainbows

Child Referral

Please fill out the form below to refer a child and I will be in touch to see in which ways we can work together.

Child’s Details

Child’s Name (required)
Date of Birth (required)

Referrer’s Name (required)
Referrer’s Relationship to Child (required ) TeacherParentSENCoOther
Family Status (eg. Lone, Step parents, carer)
Ethnic Origin
Does the child have any diagnoses? (eg. ADHD)

Is the child on medication? YesNo
If yes, please specify:

Are there any external agencies involved with the child? YesNo
If yes, please specify:

Reasons for Referral

Please state in as much detail as possible the reasons for concern:
What do you think is the cause of these behaviours?

Please list 3 things that you hope will happen as a result of seeing the Play Therapist:

Data protection

Building Rainbows is a sole trading company. This privacy policy will explain how we use the personal data we collect from you when you use our website.

Which email address can we contact you on?
and phone number if you would like to give it to us?

Child Referral

Child’s Details

Reasons for Referral

Data protection

Lets have a chat!