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P H O E N I X
HEALING ARTS THERAPY

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At Phoenix Healing Arts Therapy, we believe in the power of connection. Feel free to reach out with any questions or to schedule an appointment.

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Self Referral Form

Please fill the form to start your art therapy journey.

First name

Last name

Phone

Address

Birthday

Day

Month

Year

With whom are you currently living? (Please list names, ages, and relationship)

Please list any physical health and mental health conditions that may be relevant to your situation.

Do you have any accessibility needs or preferences (e.g., mobility, communication, sensory support)?

Yes

If it's yes, please describe.

GP’s Name:

GP’s Clinic and Contact Details:

Have you previously consulted with any mental health professionals?(tick all that apply)

Counsellor/Psychotherapist

Art Therapist

Psychologist

Psychiatrist

What was helpful in those consultations?

What was unhelpful?

What prompted you to make this appointment?

Would you like to explore any of the following?

Anxiety

Anger

Family and/ or parenting

Communication

Managing conflicts

Confidence /Self-esteem

Depression

Trauma

Separation or divorce

Trust

Stress

Are you making this referral on behalf of someone else? If so, what is your name & phone number & relationship to the person being referred?

Is there anything else about you, your background, or your current circumstances that you feel is important for me to know to best support you?

Which days and hours do you prefer for sessions?

artfts13@gmail.com

Oak Park VIC, Australia

0422400218

Accessibility Statement

Terms & Conditions

Refund Policy

Phoenix Healing Arts Therapy

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P H O E N I X HEALING ARTS THERAPY

Get in Touch

Get in touch

Self Referral Form

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P H O E N I X
HEALING ARTS THERAPY