Music Therapy Registration

Music Therapy Registration
I am registering for... *
Client's Name *

First Name Last Name
Client's Date of Birth *

Month Day Year
Date
Parent/Guardian's Name (if under 18)

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number (to be contacted on day of class) *
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Primary Language Spoken at Home *
Please select who is filling out this form. *
Please select from the list below to indicate preferred days/times for scheduling purposes. We will contact you to finalize a schedule. *
Is there anything else you would like us to know about your availability? *
Additional Client Information

Please briefly share with us why you are seeking out services. After services have been scheduled, you will have the opportunity to provide us with additional information in the intake process.
Please list diagnoses or other relevant information: *
Why are you seeking music therapy services? *
Have you received music therapy services in the past?

Yes - from Sing Explore Create Yes - from another provider No

Medical Information

We collect medical information for all in-person and virtual services. The information provided would be used should we need to contact emergency services during your time with us.
Please list any allergies. Write "N/A" if none. *
Do you have an epi-pen? *

Yes No
Emergency Contact Name *

First Name Last Name
Emergency Contact Relation to Student *
Emergency Contact Phone *
Please enter a valid phone number.
Medical Attention

In the event of an emergency requiring medical attention, I understand that Sing Explore Create, LLC will make every effort to contact and notify the listed parent/guardian and emergency contact listed above. However, if neither can be reached Sing Explore Create, LLC reserves the right to call emergency personnel to transport the student/client to the nearest medical facility to secure necessary medical treatment. This applies to sessions at our center, at-home visits, and online sessions.
*

I have read and agree to the above statement regarding medical attention.

What is telehealth?

Telehealth involves the use of electronic communications to enable Sing Explore Create's music therapists to connect with clients using interactive video and audio communications. Through these means of communication, music therapists can provide music therapy assessment, treatment, and evaluation, including music-based therapeutic experiences that are appropriate for these electronic communication.
I understand that:

1) The same confidentiality expectations for in-person services apply to telehealth. No recordings or photographs will be taken or disseminated without written consent.

2) There are risks to telehealth, despite the best reasonable efforts of our staff. These risks include the possibilities of interruptions, unauthorized access, and technical difficulties.

3) Telehealth-based services and care may be different from face-to-face services because some music therapy experiences are not possible via electronic communications; however, the quality of service will not be commpromised and the music therapists will continue to follow all clinical and ethical standards of practice.

4) All Sing Explore Create employees are mandated reporters. We are required to report any suspicions of abuse or neglect to the relevant authorities.

5) Billing will occur as usual, per Sing Explore Create policies.

6) I have the right to withhold or withdraw my consent to the use of telehealth at any time, without affecting my right to future care.
Additional Telehealth Information

The following questions will provide us with the information necessary to create a telehealth plan that works for you.
Do you have access to a device with a webcam that can connect to the internet (laptop, smartphone, computer, ipad)? *

Yes No
Do you have access to an internet connection? (high-speed preferred) *

Yes No
Are you able to operate the device (iPad, computer, etc) used for virtual services? *

Yes No
How long may the client remain engaged in a screen-based activity (video chat)? *
What, if any, instruments are available for use at home?

Music Therapy Registration

Additional Client Information

Medical Information

What is telehealth?

Additional Telehealth Information

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