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Inquiry for Music Therapy Services
Referrals and inquiries for music therapy services
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* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Contact Information
Parent/Guardian/Caregiver First Name
*
Your answer
Parent/Guardian/Caregiver Last Name
*
Your answer
Phone
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
What type of funding do you have?
*
Colorado CES Medicaid Waiver - already approved
Colorado CES Medicaid Waiver - pending
Colorado CHRP Medicaid Waiver - already approved
Colorado CHRP Medicaid Waiver - pending
Colorado SLS Medicaid Waiver - already approved
Colorado SLS Medicaid Waiver - pending
Scholarship
Grant
Trust Fund
Private Pay
Other:
Required
Client Information
Information about the person receiving services
Client First Name
*
Your answer
Client Last Name
*
Your answer
Gender
*
Male
Female
Other:
Client Date of Birth
*
MM
/
DD
/
YYYY
Client Diagnoses
*
Check all that apply
ADD/ADHD
Auditory Processing Disorder
Autism Spectrum Disorder
Cerebral Palsy
Down Syndrome
Intellectual/Developmental Disability
Medically Fragile
Mental/Emotional/Psychological Disorder
Motor Delay
Neurological Disorder
Physical Disability
Seizures/Epilepsy
Sensory Processing Disorder
Speech/Language Delay
Other:
Required
Services
What services are you interested in?
*
Music Therapy:
https://neurorhythm.com/services/music-therapy/
Wellness:
https://neurorhythm.com/services/wellness/
Individual Music Therapy
Wellness Services
Other:
Required
In what location are you seeking services?
*
Colorado Springs Clinic
Telehealth (Clients can be located outside of Colorado Springs and log in via telehealth)
Both Colorado Springs Clinic and Telehealth
Other:
Required
Do you have any comments or questions?
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
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