Registration for Individual Music Therapy Sessions or Adaptive Music Lessons

Client Name

Date of Birth

Parent/Guardian(s)

Address

Email

Phone

Reason(s) for Referral: (please include diagnosis as well as areas you would like to see improvement)

Means of communication

Musical Interests

Diagnosis and physical/cognitive/etc. challenges

Please indicate any information regarding behaviour, such as self-abuse, wandering, etc.

Any other information

Agreement

It is agreed between Major Progressions Music Therapy and client name that music therapy services will be provided for client name.

Conditions of Agreement

Responsibilities of Music Therapist

1. Individual music therapy sessions will be provided weekly or bi-weekly (with the exception of statutory holidays and scheduled breaks) at a location agreed upon by the client and the therapist.
2. Music therapist will arrive at the location on the day and time agreed upon by the client and therapist (unless there is a cancellation - *see 'Cancellation Policy').
3. An initial assessment will be completed by the music therapist following the assessment sessions (generally 3 sessions). Reports will be completed to assess and evaluate client's progress. Copies of client's progress notes may be provided upon request. Upon completion of music therapy sessions a final evaluation will be provided if requested for a fee of $25.
4. The music therapist will continue to develop her skills by practicing, planning and documenting outside of session time.
5. Music therapist will allow time at beginning or end of session for discussion of client goals, progress, challenges etc. This is a time that parents/guardians can ask questions or express concerns about anything related to music therapy sessions.
6. All client files/information will be kept confidential and secure by the music therapist.

Responsibilities of the Client

1. Clients will be present at the location of the session at the scheduled time.
2. Clients and families will communicate their needs in regard to musical or non-musical aims.
3. Clients/families will pay fees for services on time (see 'Rates & Payment Procedures')
4. Parents/guardians/clients are asked to allot an extra 15 minutes when scheduling sessions in the event that any discussion needs to take place regarding goals, progress and/or any questions related to music therapy process.

Rates and Payment Procedures

Payment for music therapy sessions/adaptive music lessons is accepted in the form of:

• Cheques made payable to Major Progressions Music Therapy.
• Electronic payment (email money transfer) by paying the invoice sent at the end of each month of scheduled sessions.
• Cash payment (a receipt will be provided by the therapist for all cash payments made).

Rates

*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.)

Cancellation Policy

1. Sessions cancelled with 24 hours notice via phone or email to the music therapist (MTA) can be re-scheduled for another date and time within the next 30 days as agreed upon by the client and therapist.
2. For sessions cancelled with 24 hours notice that cannot be rescheduled the client will not be charged
3. If a session cancellation is provided with less than 24 hours before the scheduled session, the client will pay 100% of the total session cost and may be rescheduled at the discretion of the MTA.
4. The MTA will notify the client via phone and/or email of session cancellations. Cancellations by the MTA can be rescheduled.
5. In the case of inclement weather conditions, a cancellation notice will be provided by phone and/or email at the earliest time possible.

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.