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
Prefer not to say
Preferred Phone Number
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?
Process emotions through music-related interventions
Learn a new instrument as a coping skill
Understand how to therapeutically utilize music in my everyday life
Engage in something that will provide much-needed structure to my daily routine
Provide an opportunity for my child(ren) to engage in positive music-making interventions
Receive a one-time consult and/or a therapeutic "check-up"
Please add any additional information and/or questions.
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