FMT Group Sign-Up Form
Hi there!
Before starting services, an intake form is required for all participants. By continuing to fill out this page, you are acknowledging that your confidential health information can be viewed and stored within HIPAA secure Google Forms. If you have any questions or concerns about our privacy policy, please email Info@FloridaMusicTherapy.com to request a printable intake form.
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Email *
Today's Date *
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Name of person completing form, and relationship to participant (mark self, if self reporting) *
Phone Number *
Would you like to join our email list? *
Participant Information
Please tell us a bit about the participant signing up for music therapy.
Participant's First and Last Name *
Birthdate of Participant *
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Gender
Diagnoses, if any *
What type of music therapy session are of interest?
(Please check all that apply)
 *
Music Preferences:
I'd like my music therapist to know...
How did you hear about us? *
Please list your referral's name, if we may thank them for recommending us
Payment Methods / Funding Sources *
For Gardiner / FES Only: Student ID Number:
For CMS / Sunshine Health Only: Insurance ID Number
Current Physician's First and Last Name *
Current Physician's Phone Number *
Current Physician's Fax Number *
Submit
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