Full Name
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Email
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Phone
*
(###)
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Preferred contact method
Communication Preferences
*
Please select what this contact should receive
Full Name
Email
Phone
(###)
###
####
Preferred contact method
Communication Preferences
Please select what this contact should receive
Please select your preferred payment method
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Full Name
*
Preferred Name or Nicknames
Date of Birth
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MM
DD
YYYY
Location
Address
If in person
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Availability
*
Please share the days and times that generally work best for weekly sessions at this location (e.g., Mondays 4–6 pm, Wednesdays mornings).
Is this the preferred location?
Yes
No
No preference
Secondary Location (optional)
If you are open to conducting sessions in a different location (for increased scheduling flexibility) please indicate here
Address
If in person
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Availability
Please share the days and times that generally work best for weekly sessions at this location (e.g., Mondays 4–6 pm, Wednesdays mornings).
Is this the preferred location?
Yes
No
No preference
Additional information
*
Please list any additional information I should know about accessing the location:
i.e, security, parking...
If session will be conducted at school or facility: any applicable contact information and procedures
Please write N/A if none are applicable
Relevant Diagnosis or Diagnoses
Please also list necessary accommodations, communication (e.g., speaking, non-speaking, typing, AAC, etc., and anything else I should know.
Primary Goals
What are the client's goals in other therapies? What would you like to work on or achieve through music therapy?
Interests and Preferences
Favorite songs/music styles, activities, hobbies, prior music experience, etc.
Current Therapies or Support Providers
It’s helpful for me to coordinate and communicate with other therapists or professionals involved in your care to create the most effective, personalized treatment plan. Please list any current providers and their contact information if you’re comfortable sharing (i.e., RBT, SLP, OT, PT, etc.)
