Formulario de Inscripción Centro de Musicoterapia Global (Panamá, USA, Chile)
Application Form Global Center for Music Therapy (Panama, USA, Chile)
Complete este formulario si necesita servicios de musicoterapia. (Esta información es confidencial)
Complete this form if you need music therapy services. This information is confidential and will not be shared with any other person or institution unless we are obligated by law.
Nombre de la persona contacto/Name of Contact Person
First Name
Last Name
Teléfono de la persona contacto/Phone Number of Contact Person
-
Area Code
Phone Number
Correo Electrónico de la persona contacto/Email of Contact Person
example@example.com
Nombre de la persona que necesita los servicios/Name of person who need the service
First Name
Last Name
Localidad de la persona que necesita el servicio/Address of person who need the service
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Edad de la persona que necesita los servicios/Age of person who need the service
Diagnostico de la persona que necesita los servicios/Diagnosis of person who needs service
El Centro de Musicoterapia Global provee servicios preenciales, online e híbridos, indique cuales de los siguientes elementos usted tiene/ The Global Center for Music Therapy provides on site, online, and in-person services. Select which of the following you have access to:
Buena señal de Internet/Reliable Internet signal
La aplicación Zoom/The Zoom app
Una computadora sin cámara/A computer without camera
Una computadora con cámara/A computer with camera
A mic/Un micrófono
Una cámara que puedo conectar a la computadora/A Camera that I can connect to my computer
Cualquiera de los siguientes/Any of the following: Google Hang Out, Whats Up, Facebook, Skype
Transporte para llegar al centro/Transportation
Cuidador/care taker
Liste los servicios que requiere/List the services you require
Sesión privada de musicoterapia/Private music therapy sessions
Sesión grupal de musicoterapia/Group music therapy sessions
Música y Yoga/Music and Yoga
Música y Movimiento/Music and Movement
Iniciación Musical Especial/Music Education for Special Needs
Conciertos Terapéuticos/Therapeutic Concerts
Servicios para adolescentes/Services for teens
Alzheimer and Dementias/Alzheimer's and dementias
Musicoterapia Neurológica/Neurologic Music Therapy
Salud Mental/Mental health
La Farmacia Musical/The Musical Pharmacy
Comentarios adicionales?/Any additional comments to better understand your needs?
Submit
Should be Empty: