Music Therapy Group Registration

courtney@roadstorhythmmusictherapy.com

1.204.513.1906

To register for one of our music therapy groups, please fill out the following form. Please provide as much detail as possible.

Child's Name: *

Address: *

Family Email: *

What is your child's favourite music (including specific songs, genres, types of instruments, etc.)? Least favourite music? Please be as specific as possible. *

Home Phone: *

Does your child currently receive other therapy services? If "yes", which ones? *

Which music therapy group would you like to register for? *

Parent(s) Name: *

How has your child responded to other therapy services? Have you observed progress within these sessions? *

Any other information you would like to provide about your child or your family? (This can include other goal areas that you would like addressed in the sessions, any important medical information, etc.)

City: *

Cost of registration is $110.25 (GST included) and is due October 16, 2018. Please indicate how you would like to provide payment: *

Of the following skill areas, please check off which one(s) you would like to see addressed within music therapy sessions?

Language Acquisition (speech development, increase use of verbal communication)

Language Comprehension (increase understanding of language, increase use of non-verbal communication)

Social Skills (sharing, taking turns, socially appropriate greetings, etc.)

Cognitive Skills (attention span, sensory processing, etc.)

Academic Skills (knowledge of concepts, creative thinking skills, skills related to IEP goals, etc.)

Emotional Skills (increasing self-expression, ability to self-regulate, ability to recognize emotions in others, etc.)

Other (please list down below)

Cell Phone: *

Why do you want your child to participate in music therapy sessions? *

Birthdate: *

Diagnosis (if known or applicable): *

What are your child's favourite hobbies/activities? Are they enrolled in any after-school activities? *