Music Therapy General Interest Form

Music Therapy Interest Form

Please fill out the following form to your best ability. At Middlesex Music Academy, we prioritize your safety, privacy, and well-being. Our therapist adheres to the highest ethical standards and maintains strict confidentiality. We create a safe and supportive environment where you can explore your emotions and express yourself freely through music.

Full Name*

Date of Birth (mm/dd/yyyy)*

Sex*

Your Phone*

Your Email*

Parent/Guardian Phone (if under 18 years of age)

Parent/Guardian Email (if under 18 years of age)

Age Group*

Are you exploring music therapy to improve your coping skills?

Are you exploring music therapy to build social skills?

Are you exploring music therapy for your own enjoyment or relaxation?

Are you exploring music therapy to maintain or increase physical mobility?

Are you exploring music therapy to improve your emotional wellbeing?

Are you exploring music therapy to make friends?

Are you exploring music therapy for any other reasons?

Do you currently experience stress?

Do you currently experience anxiety/depression?

Do you currently experience memory issues?

Do you currently experience physical limitaions?

Do you currently experience any other challenges?

Do you have mobility or balance issues? (check for YES)

Have you experienced a fall recently? (check for YES)

Are you willing to attend regular sessions and participate actively?

Music Preference - Country

Music Preference - Classical

Music Preference - Jazz

Music Preference - Pop

Music Preference - Rap/R&B

Music Preference - Rock

Other Music Preference (please specify)

Do you have experience with playing an instrument or singing? If yes, specify:

Do you like sports?

Do you like arts?

Do you enjoy games?

Do you enjoy socializing?

Any other hobbies? (Please specify)

Do you have any experience with attending therapy or counseling? If yes, briefly describe:

Any specific accommodations or needs?

We offer therapy sessions Monday-Friday 12-2:30 PM, Friday 6-8 PM, and Saturday 10 AM-4 PM. What times/days work for you?*