Art Therapy Referral Form - Confidential Information

About Art Therapy at Pelican Arts

Clients may ask a professional to complete this form or they may complete it themselves.

Art therapy is a type of psychotherapy where you can use art materials to improve mental health and address emotional difficulties, the art therapist works with the participant to identify and work towards therapeutic goals that go beyond relaxation and enjoyment.

We invite participants to come to therapy prepared to bring to mind their thoughts, feelings, relationships past experiences and hopes/fears for the future when attending art therapy.

Pelican Arts charges $165 per hour, sessions usually run for one hour at the Pelican Arts Studio in Mildura. We may offer a reduced fee for people who are experiencing financial hardship.

Art therapy at Pelican Arts is provided by Kate Cotching MFA, BSW, MMH (Art Therapy), (AThR). Kate is a Professionally Registered Art Therapist with the Australian New Zealand Asia Creative Arts Therapy Association (ANZACATA), Kate's Professional Membership number is 04961415.

There is currently a waitlist at Pelican Arts, completing this form will automatically add your details to the waitlist on our files, if you would like to speak to us over the phone before completing the form please contact Kate

Contact Details

Phone 0410 772 058.

email- Kate@Pelicanarts.com.au

Website pelicanarts.com.au

Client Details

Name *

Surname *

Date of Birth *

Residential address *

Phone number *

email

Primary Contact

Name *Please include relationship to client if applicable

Phone number *

Referral Information

Will the person be accessing art therapy as part of their NDIS plan? *

YesNo

NDIS number *

Support Co-ordinator contact details *

Plan Manager or details of where to send invoices *

Diagnosis on which the plan is based *

NDIS Goals as written in NDIS plan *

Reason for referral *Note - People whose sole reason for wanting to come to art therapy is to learn an art skill may find attending a quality art class more beneficial and cost-effective. If you would like information on some local arts programs please contact us via email and we can send you links to businesses and organisations that we think are worth trying.

What changes does the person hope to see if they come to therapy? *If the person is accessing therapy through their NDIS plan please specify NDIS Goals

Are there any other mental health professionals involved in this person’s care? *

Allergies *

Do you believe that the person being referred faces challenges in one or more aspects, such as emotions, focus, behaviour, or interpersonal relationships? *

They have no challenges.Yes, they have very few challenges.Yes, challenges are moderate.Yes, they face significant challenges.

Are the challenges causing distress or agitation for the individual being referred? *

Not in the slightestTo a minimal extentSignificantlyExtensively

Do the challenges disrupt the individual's daily life in the following aspects?

To the best of your knowledge, does the person pose any of the following risks? *

Please provide any information about disability, chronic medical or mental health condition to support this referral *

Confidentiality, Equality and Complaints

Confidentiality

We keep clients name and contact details on their consumer record. Other details such as case notes, care plans and information about the services received and low-resolution images of artworks are recorded in a secure file each visit. Information can only be seen by the professionals in this service involved in their care.

Any artwork created is considered a confidential part of therapy, Other people involved in their care should respect client confidentiality and not request to view or photograph artwork.

We only release information about a client if they agree or if required by law, such as in a medical emergency or if we believe someone may be at risk of serious harm.

Equalityand Child safety

PelicanArts values the contribution that all people make to society regardless of their background. If you think you are being ignored, made to feel uncomfortable or discriminated against because of your age, gender, sexuality, culture, religion or abilities please bring it to our attention so we can address the issue.

PelicanArts believes all children should be safe, happy, and empowered. We are committed to preventing child abuse and identifying risks early. The safety of children and young people is everyone’s responsibility.

Complaints and suggestions

It is important to us that we provide the best service possible to our clients and we will always listen to you no matter how big or small the problem is. You can speak with us directly, through a support person, in writing, or you can ask for a complaints form. We will try to keep you informed about what we are doing about your suggestion or problem and may ask for more feedback from you. You also have the right to make a formal complaint to the ANZACATA, the Mental Health Complaints Commissioner in your state or the NDIS.

I have read this information on Confidentiality, Equality and Complaints *

Does the person know you are making this referral? *

Yes, the person is aware that they are being referred to art therapy and I have explained how this is different to an art class.They are aware I am making a referral, but I am uncertain if they understand the difference between an art class and art therapy.They are not aware of the referral.

For information about talking to a child or participant about art therapy go to ........ insert link on website

Referrer details

Name of referrer *

Organisation

Relationship to client

Phone

Referrer e-mail address

Signature

Draw signature|Type signatureClear

Date *

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