Healing RhythmsHealing Rhythms Music Therapy Intake Form

    Client Information Form:






























    Medical History:















    PERMISSION FOR EXCHANGE or RELEASE OF INFORMATION:








    Music Therapy Pricing:




    CONSENT TO TREAT:

    I consent for Healing Rhythms Music Therapy, LLC. to provide Client


    Physical Movement:

    I acknowledge that there is always a risk of injury with any therapy involving physical activities. I hereby release Healing Rhythms Music Therapy, LLC and any agents or assignees, from any and all claims for damages related to physical movement during music therapy.




    ATTENDANCE POLICY

    Because of frequent no-shows and cancellations, Healing Rhythms Music Therapy, LLC has a policy that states that we require a 24 hour notice for cancellations.

    After a one-time occurrence, a $50 fee will be charged for EACH missed therapy appointment. This charge will be made to the clients account. We understand that sickness occurs; therefore, if you think that you are sick the night before, please call us and give us notice so we may plan accordingly, and/or contact a family who is on standby for a make-up session or on a waiting list for an evaluation or services. In the event of a cancellation, we will make every effort to reschedule, as we want you to benefit from his/her therapy. If you miss 3 consecutive weeks of therapy, we will make every attempt to hold that slot, but cannot guarantee this with an extended absence. The staff at Healing Rhythms Music Therapy, LLC strives to meet the scheduling needs of every family. If your therapy time does not work for you, please let us know




    CONSENT FOR AUDIO/VISUAL RELEASE

    I


    give permission for to be audio or video taped by the therapists by or at Healing Rhythms Music Therapy, LLC. These audio or video taped sessions will be used for education and training purposes only (i.e., clinical supervision, conference presentations).




    CONSENT FOR PHOTOGRAPH RELEASE

    I


    give permission for to be photographed by the therapists at Healing Rhythms Music Therapy, LLC. These photographs can be used for education and training purposes (i.e., clinical supervision, conference presentations), and may be used by Healing Rhythms Music Therapy, LLC for advertisement purposes (i.e., brochures, Facebook, website, and newspapers).




    Electronic Communication Waiver

    I


    give permission for the therapists and staff at Healing Rhythms Music Therapy, LLC to communicate limited information electronically for billing and communication purposes.