Self-referral form for online art therapy


The information you provide in your form and through any art therapy sessions will be treated confidentially and stored securely on Teapot Trust’s encrypted storage software, Box. This information will be used primarily for the purposes of delivering the service safely and effectively – although we may on occasion send you updates about our work unless you choose to opt out.

Information about safe boundaries during art therapy and our Child Protection policy and procedures will be explained to you in your first session and in your information pack. Please request a copy of Teapot Trust’s Online Security Policy for more information about using video calls safely and securely.

Referral Criteria for Online One-to-One Art Therapy

There are times when engaging in art therapy should not happen e.g. where a child:
• is involved in a current Child Protection investigation
• has any court Involvement
• is in an unstable placement such as interim foster care or has court proceedings pending

There are also other situations when we might recommend this is not the right time for a child to begin online art therapy as there are too many risk factors involved, e.g.:
• Family life is unsettled and there is family conflict – your child will need a secure base to support his or her therapy.
• If your child has a high number of other support interventions ongoing
• Parental mental health - parents capacity to take care of child’s needs
• Aggressive/violent behaviours from the child which may leave family members and or child at risk.
• Exposure to traumatic situations within the family home, where the child is trying to express these experiences from the place of trauma.
• Availability of other professionals members supporting the child – as part of a multi- plan approach to child’s care GIRFEC
• Whether there are enough family supports in place to help support the child.
• Children with fewer verbal skills will rely more on the art making to communicate, often working online limits the interaction with a younger less verbal child.

Art therapy may also not be suitable where a child is already receiving therapeutic support by attending Child and Adolescent Mental Health Services (CAMHS).

Please do not hesitate to contact us if you would like to discuss anything prior to submitting your self-referral form.

Details of Child’s GP

Child’s Plan

If Yes, please complete the following details:

Reason for Referral

Medical Diagnosis

Family Background

- Significant people in your child/young person’s life
- Relational dynamics within the family
- Any significant events the family and/or child have experienced, e.g. loss, trauma, abuse
- Any parental physical or mental health conditions that may impact your child

Please note the below information is solely for use in the case of a child protection situation during an online session:



Additional Information

Contact Preferences

Teapot Trust is a charity and is only able to provide this service free of charge through the generosity of our individual donors and grant funders. We, therefore, rely on feedback from those we work with to help us to promote our services and secure funding. We’d be grateful if you could tick the options, below, as appropriate. Thank you.

We will be in touch shortly to update you on the progress of your self-referral. Thank you.