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Request Group Music Therapy Services
Dynamic Music Club - Thursdays 5 pm (those with all abilities)
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Email
*
Your email
Your name:
*
Your answer
Phone number:
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Your answer
Name of individual who would receive services
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Diagnosis, if any:
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Your answer
Favorite kind of music?
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Your answer
Address:
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Your answer
Why are you interested in music therapy services?
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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?
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Yes
No
What other therapies are they currently receiving?
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Speech Therapy
Occupational Therapy
Physical Therapy
ABA
Horse Therapy
Other:
Required
Describe their current speech and communication abilities and challenges:
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Your answer
Describe their current physical abilities and challenges:
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Your answer
Describe their current social abilities and challenges:
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Your answer
Describe their current cognitive abilities and challenges:
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Your answer
When are you looking to begin services?
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Your answer
How would you be paying?
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Choose
Cash
Check
Credit card
Respite funds (through DRC)
SDFSA funds (through DRC)
If you checked respite or SDFSA above -- who is your caseworker?
Your answer
Is there additional information you feel is important?
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