Sandplay Referral - Sandstone Therapy Centre Alice Springs

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Click here for information about how to make a referral for Sandplay Therapy

Use this form to apply for your child to have individual Sandplay sessions at participating schools in Alice Springs. The session will be conducted by a therapist from Sandstone Therapy Centre in a private room provided by the school.

We will require a physical signature. This form will generate a pdf page with all the details you have entered. We then ask you to print and sign the form, then return it to Sandstone Therapy Centre.

It is important that you have read the 4 brochures we have prepared about Sandplay:

Client Rights & Responsibilities
Consumer Comments & Complaints
Privacy
Authorised Sharing

If you are the Carer, Legal Guardian or Kinship Carer of the child, proof of your legal status will be required.

This form is for 2025 enrolment. A new form will be required each year.

Student name(Required)

First Last

Date of birth(Required)

day

month

year

Country of birth(Required)

Gender(Required)

School(Required)

ATSI Status(Required)

Current accommodation(Required)

Other accommodation(Required)

You have selected other accommodation, please specify.

Would you like a copy of this referral to go to your school?(Required)

We will let the school know of your child's appointment time/day in order to be excused from class. The school does not need a copy of this form for that to happen.

Yes, send a copy to the school

No, just send this to Sandstone Therapy Centre

Preferred language(Required)

Other language preference(Required)

Please specify the preferred language.

Reason for referral

Brief description (optional)

Level of Child's Behaviour/Concern before the commencement of Sandplay Sessions.(Required)

0=High Concern/Inappropriate, 10=Low Concern/Appropriate

0 HIGH	1	2	3	4	5	6	7	8	9	10 LOW

Confidentiality Limitations(Required)

Confidentiality between clients and Sandstone Therapy Centre is maintained with limitations, such as when working with children and where it is necessary for staff to disclose client information for the proper discharge of their duties.

These include:
- where there is a legal obligation to release information such as a court order
- where withholding confidential information regarding the person or another person will put them at risk of serious harm

I have read and understand the confidentiality limitations

*Please ensure you have read the following Sandstone brochures before signing this referral form*

Client Rights & Responsibilities

Consumer Comments & Complaints
Privacy
Authorised Sharing

I/We consent to the above-named child’s

Information being collected for the purpose of assessment, treatment, case planning, data analysis & for audit & quality assurance
Sharing of information with the below signatories:

This will be emailed to the following person/people for signature.

Name Person 1(Required)

First Last

Relationship to child Person 1(Required)

Proof of legal status will be required for Carer, Legal Guardian or Kinship Carer

Phone Person 1(Required)

Email Person 1(Required)

Enter Email Confirm Email

Signature(Required)

Add a second parent/carer?(Required)

Yes

Person 2

Name Person 2(Required)

First Last

Relationship to child Person 2(Required)

Proof of legal status will be required for Carer, Legal Guardian or Kinship Carer

Phone Person 2(Required)

Email Person 2(Required)

Enter Email Confirm Email

Signature

This field is hidden when viewing the form

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Sandstone Therapy Centre Inc


ABN:	13 234 352 593
Phone:	08 8952 5899
Email:	receptionist@sandstonetherapy.org.au
Address:	21 Newland Street
	Alice Springs NT

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