Date of Birth
Reason(s) for Referral: (please include diagnosis as well as areas you would like to see improvement)
Means of communication
Diagnosis and physical/cognitive/etc. challenges
Please indicate any information regarding behaviour, such as self-abuse, wandering, etc.
Any other information
It is agreed between Major Progressions Music Therapy and client name that music therapy services will be provided for client name.
Payment for music therapy sessions/adaptive music lessons is accepted in the form of:
*HST will be applied to music therapy sessions
Individual MT: $95/hour or $75/30 mins
Invoices will be given during the last session of each month and payment is required within 15 days of receiving the invoice.
*A late payment fee of $10.00 will be charged on the following invoice if payment is not received by the due date. (Please discuss with music therapist if accommodations need to be made related to payment.)
I acknowledge that music therapy sessions/adaptive music lessons may be terminated by either party with thirty days advanced notice.
I have read and understand the above stated policies and procedures regarding this contract.
I hereby give consent for Major Progressions Music Therapy to video and/or audio record client name's music therapy sessions/adaptive music lessons. Video/audio footage may be used for educational and promotional purposes. I understand that all material used by Major Progressions Music Therapy will be shared with and approved by myself before it is used for any purpose.