Individual Older Adult Registration Form

Individual Older Adult Registration Form
Client Name
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Area CodePhone Number
Email
May this email be used for purposes of mailing documentation and/or invoices?
What is your preferred form of communication?
Date of Birth
MonthDayYear
1
Caregiver Name
First NameLast Name
Caregiver Phone Number
Area CodePhone 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?
What are your preferred types of music and/or artists?
Are there any medical needs that may arise during your music therapy sessions?
Please describe
Any questions or concerns?
Media Consent
Acknowledgement of Terms of Agreement
Should be Empty: