Community Music Enrollment Form

Facility/Group name

Coordinator's First name

Coordinator's Last name

Position

Email

Phone

Address

Session Type:

Music Therapy

Choir

1:1 Sessions

Other

If other, please specify

How large will the group be?

2-10

10 or more

What is your session length preference?

30 minutes

45 minutes

60 minutes

If more than one group to be seen during visit, please specify how many groups and desired length of session:

Goals for group:

How often would you like to have sessions? (we recommend weekly groups but can accommodate facility needs)

Weekly

Bi-Weekly

Monthly

Once your form has been reviewed, you will receive a contract to be signed and sent back before your first scheduled session. (One time groups do not need a contract.)

Thank you!

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