Refer A Family is to be used by Medical Professionals or Caregivers of Palliative Children
( children that need urgent sessions )

Unfortunately we do not accept referrals for non - urgent cases. If you know a family that would benefit from a session please have them apply themselves. 

Name *
Name
Your Name
Your Phone Number *
Your Phone Number
This is only important if the child is currently in hospital. Please provide us with an address and a way to contact the family in hospital.
Family Information
Mother/Fathers or Guardian's Name *
Mother/Fathers or Guardian's Name
Address of the family
Address of the family
if you have this, please provide this for us.
Phone Number of the family *
Phone Number of the family
Child's Name *
Child's Name
Does The Family Know You Are Referring Them? *