Referral/Intake Form

Sign up for music therapy sessions by completing the form below.  

All information is confidential.  

Only a board certified music therapist will be able to view the information submitted.  Your information will never be shared, sold, or used for promotional purposes.  


Please complete the form below

Client Name *
Client Name
Accessibility *
Do you require an accessible location? I.e. Are you able to walk up two flights of stairs to a music therapy studio?
Would you like to receive emails notifications of upcoming groups, news, and FYV promotions? *