Music Therapy Assessment Registration Form Please check which instrument(s) your child has previous exposure to: Piano Guitar Voice Violin Electric Bass Drums Theory OtherOther Assessment Length 45 minutes 74.25 60 minutes 99.00 Preferred Assessment Date & Time * Alternate Assessment Date & Time Name * First Last * Last Phone Number * Email * Name and Age of Client * Text Address * Is the client involved currently with other therapies? If so, please indicate which one(s). If not, please indicate "none." * Client has responded most positively to these techniques, tools, therapies, etc. in the past Relevant Medical Information (eg. allergies, medication, etc.) Emergency contact information in addition to the person filling in this form. Name, Cell Phone, Relationship to student. * Parent/Client/Team goals in therapy * Any additional information you would like us to know I understand that, once confirmed by email/text, there is no refund available and that I will need to purchase another assessment if I need to reschedule. * Agree I would like to use the following method of payment to secure my assessment * Visa MasterCard E-transfer Direct Billing - Please upload an attachment (picture, scan, or file) of your letter of approval from the Autism Funding Branch, Ministry of Children and Family Development below If choosing the direct billing method please upload an attachment (picture, scan, or file) of your letter of approval from the Autism Funding Branch, Ministry of Children and Family Development here Drop a file here or click to upload Choose File Maximum upload size: 67.11MB Additional information or message: If you are human, leave this field blank.