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 Request Individual Music Therapy Services
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* Indicates required question
Email
*
Your email
Your name:
*
Your answer
Phone number:
*
Your answer
Name of individual who would receive services
*
Your answer
Age
*
Your answer
Diagnosis, if any:
*
Your answer
Address:
*
Your answer
Why are you interested in music therapy services?
*
Help with social skills
Help with speech and communication
Help with motor skills
Help with cognition and academic skills
Help with behaviors
Other:
Required
Has this individual had music therapy before?
*
Yes
No
What other therapies are they currently receiving?
*
Speech Therapy
Occupational Therapy
Physical Therapy
ABA
Horse Therapy
Other:
Required
What days/times work? (Our hours are Monday-Saturday from approximately 9 am to 7 pm)
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Your answer
When are you looking to begin services?
*
Your answer
How would you be paying?
*
Choose
Cash
Check
Credit card
Respite funds (through DRC)
SDFSA funds (through DRC)
If you checked respite or SDFSA above -- who is your service coordinator?
Your answer
Is there additional information you feel is important?
Your answer
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