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Group Interest Form
Please answer these questions from the potential client's perspective
All groups will begin in September and
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Clients Name
*
Your answer
Email Address
Your answer
Phone Number
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Which of these group types interest you?
*
General Music
Music and Movement
Songwriting
Music Technology / Recording
Verbal Processing (We will use songs and lyrics to talk about what's happening in your lives, teens and adults only)
Forming a Band
Parent/Child Music Class
Required
Please also contact me with information about Individual services
Yes
No
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Why are you interested in music therapy?
Your answer
What diagnoses or needs do you feel are relevant for us to know?
Your answer
What do you hope to get out of the group?
Your answer
When are you generally available?
Tuesday Late Afternoon / Evening
Thursday Morning/ Early Afternoon
Thursday Late Afternoon/Evening
Saturday Morning/ Early Afternoon
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