Full name*

Email*

Phone*

We’d love to keep you up to date with our latest resources, news, events and ways to get involved. Are you happy to join our mailing list?

Yes

Are you enquiring for yourself, or somebody else?

Are you getting in touch for yourself or on behalf of somebody else?*

I’m enquiring for myself

I’m enquiring on behalf of someone else

(If you’re getting on touch on behalf of someone else we’ll collect their details at a later date).

What's your relationship to the person being referred?*

Name of the person being referred for music therapy*

Age Group (of the person being referred for music therapy)*

Please tell us why you're enquiring

Please tell us a little about why you're enquiring about music therapy*

Include relevant details about specific needs, including any conditions that our music therapists should be aware of.

Is the condition of the person being referred for therapy terminal or critical?*

Yes

Please give details*

Although we wish we were able to meet every request, it is not possible due to the very high demand for our music therapy sessions. If your condition is terminal or critical, we will see you as soon as possible.

How did you hear about the group?*

Wider Offer Signup – Adult Afternoon Group

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Are you enquiring for yourself, or somebody else?

Please tell us why you're enquiring