JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Creative Arts Therapy Client Intake Form
Welcome! Interested in our creative arts therapy or teaching artist services? Please fill out the form below and we will get back to you as soon as possible to schedule an assessment and pair you with the right fit for your needs.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Client or Facility Name (clients first name or initials)
*
Your answer
Your Name (full name)
*
Your answer
Email
*
Your answer
Phone number
*
Your answer
Full Address & Zip Code
*
Your answer
Relationship to Client or Facility?
*
Your answer
Client's Age or Groups Age Range
*
Your answer
Reason for Referral?
(why are you seeking music therapy or related services)
*
Your answer
Availability
(please list the best days/times for sessions to take place)
*
Your answer
Preferred Language
*
Your answer
Anything else we should know?
Your answer
How did you hear about us?
*
Your answer
Which service are you interested in? (Check all that apply)
*
Art Therapy
Dance Therapy
Drama Therapy
Music Lessons
Music Therapy
Teaching Artist
Required
Which options are you interested in?
*
In-Office Services (Los Angeles - Koreatown)
Virtual Services (U.S. and abroad)
In-Home Services (depends on address and availability)
On-Site (for schools, facilities, RTCs, community centers, nursing homes, STRTPs, etc)
Other:
Required
Free Virtual Assessment?
*
Yes
No
Maybe
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Rhythm & Truth.
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
