Music Therapy Assessment Registration Form

Please check which instrument(s) your child has previous exposure to:

Assessment Length

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 *

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

Maximum upload size: 67.11MB

Additional information or message: