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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.
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Name of Individual Receiving Services
*
Your answer
Age
*
Your answer
Gender
*
Female
Male
Prefer not to say
Other:
Preferred Phone Number
*
Your answer
Email Address
*
Your answer
Has the individual seeking services received previous psychological care and/or counseling services?
*
Yes
No
If "Yes", please elaborate.
Your answer
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"
Other:
Please add any additional information and/or questions.
Your answer
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