Music Therapy Support Group Registration
Register to join our supportive music therapy group. Please complete all fields to help us understand your needs and preferences.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact Name
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any medical conditions, allergies, or accessibility needs we should be aware of?
What are your primary goals or reasons for joining the music therapy group?
*
Preferred Group Session Times
*
Weekday mornings
Weekday evenings
Weekend afternoons
Other (please specify)
Have you participated in music therapy before?
*
Yes
No
If yes, please briefly describe your previous experience.
Signature
*
Register
Register
Should be Empty: