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PMT New Student Questionnaire
Welcome to the studio! Information on this form will help our staff to prepare for student's first lesson and curriculum to follow. Questions as you complete it? Email:
Director@piedmontmusictherapy.com
or Call Main Office: 803-206-2044.
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* Indicates required question
Student's First & Last Name
*
Your answer
Birth date
*
MM
/
DD
/
YYYY
If applicable: Parent/Guardian's Name
*
Your answer
Focus/Instrument:
*
Composition
Guitar
Percussion
Piano
Trombone
Ukulele
Voice
Other:
Required
If applicable: School and Grade
Your answer
Mailing address:
*
Your answer
Email address:
*
Your answer
Phone number:
*
Your answer
How did you hear about our studio?
*
Your answer
Diagnosis(es):
Your answer
Medication that may impact lessons:
Your answer
Sensory needs:
Your answer
Preferred communication:
Verbal
American Sign Language
Technology Device
Pictures
Other:
Please detail music-making in the home setting (i.e. amateur, leisure, professionally):
Your answer
Please describe any involvement in church or school music programs:
Your answer
What style of teaching does or does not work well for the student?
Your answer
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