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.

Covid Guidelines
We appreciate your understanding that our services fall under many categories, given that we provide both recreational and therapy services for all ages. The policies below were created after thoroughly reviewing guidelines from the CDC, Governor Baker's office, Department of Ed., Department of Early Education and Care, and Department of Developmental Services. We will continue to review and update our policies as necessary. Updates may be found at: https://singexplorecreate.com/covid-19-response/

Updated February 15, 2022

Facemasks

As of 2/21/22, Facemasks are OPTIONAL for students, clients, and staff in our center. All members of SEC staff are fully vaccinated.

Hand Hygiene

All visitors (including staff) are asked to wash their hands with soap and water or use hand sanitizer upon arrival.
SEC Staff are required to wash/sanitize their hands between each group or individual session.

Screening for illness/Quarantine Requirements

Please do not enter the center if you are sick. If you are sick or required to quarantine for any reason, please contact us to postpone your services or arrange for virtual services until it is safe for you to return to the center.
We have adopted the CDC's new guidance around testing positive and being close contacts:Students/Staff who test positive, will be allowed to return to in-person services after 5-days from the onset of symptoms or a positive test, so long as symptoms have subsided.
Individuals should remain masked at all times while in the center for the 5-days following their 5-day isolation/quarantine period.
No one should enter the center if continuing to experience symptoms.
If any visitor gets sick while at the center, SEC staff will guide them to a separate area away from others until they are picked up or able to safely leave on their own. Caregivers will be contacted immediately if an individual becomes sick in our center and needs to be picked up.

Cleaning

All surfaces, instruments, and other materials are cleaned between every session.
Bathrooms and common areas are regularly cleaned throughout the week by staff, as well as once per week by a cleaning company.

Air Quality

HEPA air filters are operating in every room and our HVAC system is updated and operating with maximum outdoor air exchange.
Use of Instruments/Materials

Students and therapy clients will be allowed to use and share instruments and materials. Any item that is “mouthed” or otherwise contaminated will immediately be removed from use and fully disinfected or disposed of appropriately after the sessions

QUESTIONS:

admin@singexplorecreate.com
By checking below I certify that: *

I have read and agree to the policies and information provided above I will adhere to all health and safety policies of Sing Explore Create, LLC (subject to change based on most current CDC and state guidelines)
Enter your name below. This will serve as your electronic signature, and indicates that you agree to the above terms and conditions. Parents/Guardians may sign on behalf of their children. *
Name (Electronic Signature)

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

Covid Guidelines

What is telehealth?

Additional Telehealth Information

Media Permissions

SEC Newsletter