Heartland Music Therapy Request for Session

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Participant Name: *

First

Last

Date of Birth (MM/DD/YYYY): *

MM/DD/YYYY

Parent/Guardian Name (if under 18): *

First

Last

Address: *

Email *

Phone Number: *

I would like to discuss more about the following:

• Individual Music Therapy Screening
• Individual Music Therapy Assessment (6 sessions)
• Individual Music Therapy On-going (need to complete Assessment sessions
• Healing Sounds and Beat for Parkinson’s
• Music for Seniors

Submit

Program Policies & Expectations *

• Cancellation: I understand that at least 24 hours’ notice must be given to cancel or reschedule an individual lesson. A missed lesson or a last-minute cancellation (less than 24 hours’ notice) will count as a paid session.
• Payments: Different for each program. Please ask the office.
• Heartland Music Therapy Services reserves the right to take and use photographs of individuals using Amadeus Square for the Arts and/or participating in programs by Heartland Music Therapy Services, Alpha Bell Music and Creative Arts Alliance. Such photographs are the property of Heartland Music Therapy Services and may be used in brochures, advertisements, and other promotional materials.