Music Therapy Enrollment Form

Client First name

Client Last name

Client's Birthday

Month

Day

Year

Caregiver Name

Email

Yes, subscribe me to your newsletter.

Phone

Preferred method of contact

Text

Phone call

Email

Address

Which location are you interested in?

Hamburg, NY

Williamsville, NY

Bradenton, FL

In Home (travel fees may apply)

Preferred Length of Session

30 Minutes

45 Minutes

60 Minutes

Will you be using any of the following for reimbursement?

OPWDD self-directed budget

FES-UA

Diagnosis or reason for seeking Music Therapy?

What would you like addressed in Music Therapy?

It's not necessary, but does the client have any musical experience?

What are the client's preferred types of music/artists?

Are there any medical needs that may arise during music therapy sessions?

Yes

No

If yes, please describe.

Any questions or concerns?

Social Media Photo Consent: Please indicate below your preference for photo release permission.

Yes, I do agree

No, I do not agree

By signing below I acknowledge and agree to the above payment and attendance policy.

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