Harmony Music Therapy Scholarship Application
Thank you for your interest in Harmony Music Therapy! We are thrilled to be able to offer one $300 scholarship to benefit children with special needs age 0-18 in group or individual settings.
Client Name (person who will receive services)
Your answer
Parent/Guardian Name (contact person)
Your answer
Relation to child
Your answer
Email
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Phone
Your answer
City of Residence
Your answer
How did you hear about Harmony Music Therapy?
What is your annual household income?
# Dependents
Client Age
Your answer
Client Diagnosis (if any)
Your answer
Please describe any concerns you have about your child
Your answer
Why are you seeking music therapy for your child? What do you hope to gain?
Your answer
How much would you be able to comfortably contribute to each session? (please note the more you contribute the more sessions we can provide).
Please list any other services your child is currently receiving
Private pay
Paid for by outside party
Speech Therapy
Occupational Therapy
Physical Therapy
Applied Behavioral Analysis (ABA)
Any additional comments on why you feel you are a strong candidate for our scholarship
Your answer
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