ColourMeIn
Wellbeing

Art Therapy Application and Assessment Form - Adults

This form is to be completed by the person seeking art therapy. It helps ensure that therapy is appropriate and tailored to your needs. All information is treated in strict confidence and handled in accordance with HCPC and BAAT guidelines.

Personal Details

First name

Last name

Date of Birth

Day

Month

Year

Gender

Preferred Pronouns (if applicable)

Address

City / Town

Post Code

Contact Number

Preferred method of contact

SMS

Phonecall

Background Information

Reason for referral (please provide a brief summary)

Do you have a diagnosis that the therapist should be aware of (e.g., ASD, ADHD, PTSD)?

Have you received any previous or current support (e.g., mental health services, counselling)?

Are there any family circumstances you feel are relevant (e.g., bereavement, separation)?

How do you express your feelings and emotions?

Medical and Accessibility Needs

Do you have any medical conditions or allergies?

Do you require any additional support or reasonable adjustments (e.g., mobility, communication)?

Do you give permission for the therapist to contact your GP if needed to support your therapeutic process? If so, please provide contact details.

Are there any eating difficulties or issues around food that we should be aware of? Please provide details if applicable.

Are there any sensory difficulties related to noise, textures, or art materials that we should be aware of?

Consent

I confirm that the information provided above is accurate to the best of my knowledge. I understand this information will help the therapist assess the suitability of art therapy for me and plan therapeutic support.

Yes

ColourMeIn Wellbeing

Art Therapy Application and Assessment Form - Adults

Personal Details

Background Information

Medical and Accessibility Needs

Consent

ColourMeIn Wellbeing

Accreditations

ColourMeIn
Wellbeing

ColourMeIn
Wellbeing