Tele-Music Therapy Intake Form
One of our music therapists will contact you within 24-48 hours upon submission of this form. Any information shared on this form will remain confidential, as per standard HIPPA requirements.
Name of Individual Receiving Services *
Age *
Gender *
Preferred Phone Number *
Email Address *
Has the individual seeking services received previous psychological care and/or counseling services? *
If "Yes", please elaborate.
What would the individual seeking services like to accomplish in tele-music therapy sessions?
Please add any additional information and/or questions.
Never submit passwords through Google Forms.
This form was created inside of Report Abuse