Individual Older Adult Registration Form
Client Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
May this email be used for purposes of mailing documentation and/or invoices?
*
Yes
No
What is your preferred form of communication?
*
Phone
Text
Email
Date of Birth
*
-
Month
-
Day
Year
1
Caregiver Name
First Name
Last Name
Caregiver Phone Number
-
Area Code
Phone Number
Caregiver Email
example@example.com
What would you like addressed during music therapy?
Diagnosis or reason for seeking music therapy services?
It's not necessary, but do you have musical experience?
Yes
No
What are your preferred types of music and/or artists?
Are there any medical needs that may arise during your music therapy sessions?
*
Yes
No
Please describe
*
Any questions or concerns?
Media Consent
Acknowledgement of Terms of Agreement
Submit
Should be Empty: