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
To select multiple options for questions below regarding availability and location preference, hold down CTRL (or CMND for Mac) on your keyboard.
On receipt of your completed Creative Arts Therapy Request Form, the Creative Arts Therapy Service Coordinator will contact you by email. The Coordinator will send you an email to seek confirmation regarding the suitability of a time to take a video call. Please be mindful that you may require privacy to take this video call. Please indicate below the days and times that work best for you to take the call. *Mon 12-2PMMon 4-8PMTues 12-2PMTues 4-8PMWed 12-2PMWed 4-8PMThur 12-2PMThur 4-6PM
Please indicate your prefered location for Creative Arts Therapy: Neurolinks Clinic SandyfordInsight Matters Capel StreetPhibsboroughLeopardstownMallow
Please indicate the days and times that you would potentially be available for Creative Arts Therapy.Monday 9 AM – 1:30 PMMonday 1:30 PM – 5:30 PMTuesday 9 AM – 1:30 PMTuesday 1:30 PM – 5:30 PMWednesday 9 AM – 1:30 PMWednesday 1:30 PM – 5:30 PMThursday 9 AM – 1:30 PMThursday 1:30 PM – 5:30 PMFriday 9 AM – 1:30 PMFriday: 1:30 PM – 5:30 PMWeekday Evenings: 6 – 9 PMSaturday: 9 AM – 1 PMSaturday: 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 person? *YesNo
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? *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? *YesNo
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 TherapyDance Movement TherapyMusic TherapyDrama 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.
