New Patient Assessment Form

Music Therapy has impacted the health of millions worldwide in a clinical proved, non-invasive and natural way. Fill out the form to request a 15 minute free consultation from one of our certified professors. Generally, after the consultation we will customize a treatment package for you. The model will be either: 1-on-1, 1-on-1 with patients/ siblings, 1-on-group.
Full Name*
What best describes patient*
- Please Select One
- Child
- Adult
- Senior
What best describes patient
Please Describe Your Symptoms*
How Long Have You Had These Symptoms*
Email*
Contact Number*
This form is for first time 15 minute consultation only. After consultation we will set up a one hour assessment. If you are a current patient and would like to make appointment, please go to the appointment form.*
This form is for first time 15 minute consultation only. After consultation we will set up a one hour assessment. If you are a current patient and would like to make appointment, please go to the appointment form.