Participant or Group Name
*
First Name
Last Name
Personal Pronouns
*
Birthdate
*
2nd Participant Name (...If applicable)
First Name
Last Name
Personal Pronouns (2nd participant... if applicable)
Birthdate (2nd participant...if applicable)
Primary Contact Person
*
First Name
Last Name
Contact Number
*
(###)
###
####
Contact Email
Address (if applicable)
What is your relation to the participant(s)?
Are you the POA?
*
(POA = Power of Attorney)
Location
*
Bermuda
Kingston, ON
YGK Area
Ontario (outside of YGK Area)
Canada (outside of Ontario)
Other
Session Preference:
*
Online/Virtual
In-Person
Hybrid
No Preference, open to either
If "other", please explain...
Ideal session length (Check all that apply):
*
(Note: special program groups are only available as 60-minute sessions).
Tell us a little about why you are wanting therapy?
*
What are your musical preferences?
*
(Favourite songs, artists, genres, etc.)
What hobbies or activities do you enjoy for fun?
(e.g. gardening, travel, sports, video games, cooking, square dancing, art, sewing, boating, time with friends/family etc.)
Do you have previous musical experience?
*
If yes, please share more about your musical history...
Are you receiving another therapy service?
*
If yes, you have the option to share more with the MTA (including therapy type, therapist contact details, comments on experience, etc.)
Note: This is not mandatory or required. You do not need to share if you prefer not to.
What time of the week/day works best for you?
*
Is there anything else you wish us to know?
(Past Experience, Diagnoses, Physical Abilities, Triggers, etc.)
How did you hear about us?
