Creative Art Therapies
Enhance your psychological wellbeing using the language of art; your language.
Name *
Date of Birth *
Phone Number *
Email Address *
Address
City
County *
Eircode *
Emergency contact name *
Emergency contact phone number *
Relationship to client
Sector of the Arts and role: *
Are you available to attend 10 weekly sessions in person from 7 PM - 8:30 PM at Insight Matters, Capel Street? *YesNo
Please briefly outline your reason for seeking Group Dramatherapy at this time i.e. what you hope to gain from engaging in Group Dramatherapy, in what areas of your life would you like to see positive changes:
In order to help inform suitability for a short-term intervention, please complete the following brief survey. This survey may be repeated during the initial online meeting.
Please respond to each of the next 5 items by selecting one answer from the dropdown, regarding your overall wellbeing in the last two weeks.
I have felt cheerful and in good spirits.Please select one of the following...All of the timeMost of the timeMore than half the timeLess than half the timeSome of the timeAt no time
I have felt calm and relaxed.Please select one of the following...All of the timeMost of the timeMore than half the timeLess than half the timeSome of the timeAt no time
I have felt active and vigorous.Please select one of the following...All of the timeMost of the timeMore than half the timeLess than half the timeSome of the timeAt no time
I woke up feeling fresh and rested.Please select one of the following...All of the timeMost of the timeMore than half the timeLess than half the timeSome of the timeAt no time
My daily life has been filled with things that interest me.Please select one of the following...All of the timeMost of the timeMore than half the timeLess than half the timeSome of the timeAt no time
Are you currently engaging in any other form of therapy? YesNo
If yes, please give details:
If you have had any mental health concerns in the last 6 months that you consider important for us to be aware of, please provide details:
Do you have any visual, hearing, or physical difficulties that you feel would be helpful for us to be aware of?YesNo
Do you have any medical conditions that you feel would be helpful for us to be aware of? Please note if there are any mental health conditions that are not disclosed at the time of application, we may need to review suitability for this short-term Creative Arts Therapy intervention. *YesNo
Minding Creative Minds is committed to ensuring that your confidentiality and privacy is respected and upheld. The details you provide in this form will be stored securely in line with best practice and GDPR requirements. If you engage in Creative Arts Therapy with one of our Creative Arts Therapists, they will read your Request Form before your initial session. Your information will not be shared outside our Creative Arts Therapy service, unless we believe you are at imminent risk of harm (or a child or vulnerable adult is at a serious risk). In this instance we are legally bound to share basic information in order to keep you and/or a vulnerable other, safe. As the safety of our clients is our highest priority, therapy will be discontinued if at any point in the 10 week intervention the Creative Arts Therapist deems short term Creative Arts Therapies inappropriate or unsafe for the client. In ticking “accept” below, you are confirming that you have read this declaration and are agreeing to the terms of the service.
Accept *
Date Accepted *
Once received our Creative Arts Therapy Service Coordinator will contact you to confirm your details and arrange an initial online meeting to discuss the Dramatherapy Group.
