Referral Form

Amy has openings for booking.

You do not need a referral from a GP or professional- you can complete the form below.

Amy Lacey Art Therapy collects and retains personal information about clients for the purposes of providing informed art therapy services. Information is managed in accordance with legal and ethical guidelines of the profession and the Privacy Act 1988. Once submitted, the completed referral from is forwarded directly to hello@amylaceyarttherapy.com.au. Amy will contact you within 3 business days of receiving the referral.

Name- Person Completing the form

First Name

Last Name

Phone

(###)

###

####

Organisation

If making a referral on behalf of someone else.

Who is the referral for?

Myself

My child

On behalf of someone else

How will art therapy be funded?

Reason/s for art therapy referral

please provide as much detail as possible to help me understand your needs for me to determine if my services are suitable.

What are your hopes for art therapy?

Preferred start date or day of the week

I work Monday-Thursday. Please provide at least 2 options.

Preferred contact method

Phone call

Other Enquiries

You are welcome to send any other enquiries or questions about my art therapy services.

Referral Form

Other Enquiries

Working Hours

Clinic Locations