Name *
Date of Birth
Phone Number *
Email Address *
Address
City
County
Eircode
Emergency Contact Name *
Emergency contact phone number *
Relationship to client
On receipt of your completed Creative Arts Therapy Request Form, the Creative Arts Therapy Service Coordinator will contact you by phone. The Coordinator will send you a text before phoning to seek confirmation regarding the suitability of the time to take the call. Please be mindful that you may require privacy to take this call. Please indicate below the days and times that work best for you to take the call. To select multiple options hold down CTRL (or CMND for Mac) on your keyboard. * Mon 12-2PM Mon 4-8PM Tues 12-2PM Tues 4-8PM Wed 4-8PM Thur 12-2PM Thur 4-6PM
Please indicate the days and times that you would potentially be available for Creative Arts Therapy: Mon 10 AM - 1 PM Thur 9 AM - 1:30 PM Thur 1:30 PM - 5:30 PM Thur 6 PM - 9 PM Sat 9 AM - 1 PM Sat 1 PM - 5 PM
If none of the above days and times suit, when would you potentially be available for Creative Arts Therapy:
Sector of the Arts and role:
Are you available to attend weekly sessions in Sandyford, D18 N7V7 * Yes No
Please briefly outline your reason for seeking Creative Arts Therapy at this time i.e. what you hope to gain from engaging in Creative Arts Therapy, in what areas of your life would you like to see positive changes:
Are you currently engaging in any other form of therapy? * Yes No
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? Yes No
If yes, please give details:
Do you have any medical conditions that you feel would be helpful for us to be aware of? * Yes No
If yes, please give details:
Please indicate if you have a preference of Creative Arts Therapy modality. While we will try to facilitate your preferred option please be aware that this may not always be possible as allocation will be based on therapist availability. To select multiple options hold down CTRL (or CMND for Mac) on your keyboard. Art Therapy Dance Movement Therapy Music Therapy Drama Therapy
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 12 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 review your request for Creative Arts Therapy and will contact you to confirm your details and ensure that we have an accurate understanding of your request. If Creative Arts Therapy is agreed to be the best option a Creative Arts Therapist will be assigned to you.
