Remote Music Therapy Services Agreement
Music Therapy of the Ozarks was awarded a grant from the Community Foundation of the Ozarks (CFO) to provide access to music therapy for older adults in isolation at assisted living facilities via teletherapy and technology. Music Therapy of the Ozarks will be contracting with the Center for Music Therapy and Wellness to provide these services.
All services will be provided by a board-certified music therapist.
Assisted Living Facility Name
Date*
Month Day Year
Assisted Living Facility Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number*
Area Code Phone Number
E-mail*
Title
Resources that will be checked out to your facility to use during the 16 week program*
Apple Ipad Apple Ipod On-Ear Headphones
Tentative Week by Week Schedule
Week 1: 1 hour of creating a video for all members of the facility; 2, 15-minute individual sessions with referred residents
Week 2: 30 minutes creating playlists for specific residents; 4, 15-minute individual sessions with referred residents
Week 3: 1 hour of singing outside windows at assisted living facilities; 30 minutes of creating playlists for specific residents
Week 4: 6, 15-minute individual sessions with referred residents
Week 5: 1 hour of creating a video for all members of facilities; 30 minutes of creating playlists for specific residents
Week 6: 4, 15-minute sessions with individuals; 30 minutes of creating playlists for specific residents
Week 7: 1 hour of singing outside windows at assisted living facilities; 2, 15-minute sessions with individuals
Week 8: 4, 15-minute sessions with individuals; 30 minutes of creating playlists for specific residents
Week 9: 1.5 hours creating “make your own instrument” packets and a video to be delivered to facility for residents
Week 10: 6, 15-minute sessions with individuals
Week 11: 45 minutes of creating playlists for specific residents; 45 minutes of singing outside of windows at assisted living facilities
Week 12: 6, 15-minute sessions with individuals (beginning closure of therapeutic relationship)
Week 13: 1 hour of creating a video for all members of facilities; 2, 15-minute sessions with individuals (closure sessions)
Week 14: 6, 15-minute sessions with individuals
Week 15: 1 hour of singing outside of windows at assisted living facilities; 2, 15-minute sessions with individuals (closure sessions)
Week 16: 1 hour of creating a closure video session for all residents; 2, 15-minute sessions with individuals (closure sessions)
History of Pathology
1. List Areas of Discomfort or Pain*
2. Describe Onset of Discomfort or Pain*
5. At what time of day is the pain at its worse?*
Morning Afternoon Evening During Sleep
6. Have you ever injured this area before?*
7. Have you ever been in an accident (automobile, work, falls, etc.) ?*
8. List all related treatments received for this injury.
9. Have you ever received therapeutic massage for a specific problem or injury?
Was the treatment used effective?
10. Is there anything that you do that creates, increases or decreases pain?*
11. What are the physical duties required of your occupation?*
12. What activities/hobbies do you enjoy?*
13. Please list exercise and stress reduction activities (including frequency).*
14. In what position do you most often wake up?*
Back Side Stomach
15. Are you currently seeing any other healthcare professional?
Please check any symptoms that apply to you and indicate right or left when applicable:
Legs and Feet
Pain down RIGHT leg Pain down LEFT leg Pain down BOTH legs Leg cramps Pin & Needles in RIGHT leg Pin & Needles in LEFT leg Numbness in RIGHT leg Numbness in LEFT leg Numbness in RIGHT foot Numbness in LEFT foot Numbness in toes Feet feel cold Cramps in RIGHT foot Cramps in LEFT foot Swollen RIGHT ankle Swollen LEFT Ankle Swollen RIGHT foot Swollen LEFT foot Pain in RIGHT Foot Pain in LEFT Foot Pain in RIGHT knee Pain in LEFT knee Diagnosed Arthritis
Client Agreement:
I understand that we are to pay $45 per week for 16 weeks for the Remote Music Therapy program provided by the Center for Music Therapy and Wellness.
I acknowledge and understand that our staff will be responsible for the following:
- Assist inside the facility
that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.
It is my choice to receive therapeutic massage as a form of therapy.
I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction.
I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust.
I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.
I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Pure Touch Therapy and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.
By my electronic signature below, I agree to the massage policy and client agreement above.
Signature*
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse. Clear
Should be Empty: