Music Therapy Policies and Consent Forms

Child's Name*

First NameLast Name

Date of birth

Date

Parent/Guardian Name (if client is under 18)

First NameLast Name

Phone Number

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

It is our goal at Noteworthy Music Therapy to provide you with outstanding services, support, and communication regarding your family’s needs. We provide an environment that is encouraging, evidence-based, and enjoyable for each child. We want you to be an integral and active participant in your child’s therapy and learn how to provide an environment for your child and family that will support his/her development. We also want you to be involved in establishing goals, treatment planning, home exercises, and discharge planning. Our intention is to move towards a level of independence and success within everyone’s abilities.

Consent to Treat

I, as parent/guardian, consent for Noteworthy Music Therapy and its therapists to provide my child with music therapy services. I consent to care and treatment falling under the guidelines and scope of practice established by the American Music Therapy Association. I acknowledge that there is always a risk of injury with any therapy involving physical activities.

Parent/Guardian initials, indicating you give consent to treat:*

Attendance Policy

Clients/families will have an established schedule for music therapy sessions, agreed upon between you and your therapist (day of the week, time slot, and frequency)
In the event a therapist needs to cancel a session (due to illness, emergency, travel plans etc), she will provide client families with as much advance notice as possible and offer the opportunity to reschedule a makeup session.
In the event that a client/family needs to cancel a session, please make every effort to provide as much advance notice as possible. 24-hrs prior notice is preferred, but in emergencies, please just reach out to your therapist asap before the scheduled session time.
If a client/family is a "no show" for a session (fails to show up at clinic for session without notice, or is not home when therapist arrives at your house for session), you may be subject to being billed for the session at the standard rate. Repeated no shows may result in loss of your child's spot with that therapist.

Parent/Guardian initials, indicating your understanding of attendance policy:*

Billing Policy

Upon starting music therapy services, client families will be notified of the cost ("rate") for each MT session. The rate is determined based on the length of each session (typically 30, 45 or 60 min). Small additional fee may be added to the rate for travel/distance, in cases where sessions take place outside of our general service area (which includes Mt. Pleasant, West Ashley, Charleston, Goose Creek and Summerville areas).
If client families have been awarded a grant to fund some or all of their music therapy costs, Noteworthy will take care of maintaining session records and billing the grant organization according to their policies. Families will be notified as grant funds are close to being depleted, and advised on opportunities to reapply.
When grant funds have been fully used, but before a grant renewal might occur, parents may choose to continue a consistent schedule of MT services by paying out of pocket during that interim time frame. If parents choose to put MT services on a temporary break while waiting for a new grant to be awarded, NMT therapists will do their best to hold that child's time slot so that services can resume at the earliest opportunity. If the child's spot cannot be held, families will be notified and we will assist them in finding another time slot or another therapist on our team if possible.
For families who choose to pay out of pocket or do not qualify for grants, we will establish a payment schedule with you and a preferred method of payment. Payments can be made at the time of service, or on a monthly or biweekly basis, as families prefer. Methods of payment include cash/check, Venmo or Paypal, as well as credit card when paying directly through our invoicing system.
If payments are not made in a timely manner, reminders will be given by your therapist which may include a re-sending of your emailed invoice (stating the dates of service and the charges outstanding). Failure to pay an outstanding balance despite reminders, and after a grace period, may result in a termination of services. You may contact Jennifer or your therapist confidentially if there are circumstances affecting the ability to pay, and to set up a payment plan to resolve the outstanding balance.

Parent/Guardian initials, indicating your understanding of billing policy:*

Permission for Exchange of Information

I authorize Noteworthy Music Therapy to exchange necessary and pertinent information with physicians, case managers, therapists or other health care providers as needed for my child. Approved information includes written documents and/or verbal discussion. Information exchange is vital to a successful treatment team and collaboration with other professionals.

Parent/Guardian initials

Approved information may be exchanged with the following people:

Please list providers/therapists' names and contact information

Photo/Video and Social Media Release

I give permission for my child to be photographed/videoed by therapists of Noteworthy Music Therapy. These photographs will only be used for education and training purposes (i.e. clinical supervision, conference presentations), or for use by Noteworthy Music Therapy for advertisement purposes (i.e. brochures). The child's full name and identity will remain confidential at all times.

Additionally, I give permission for photographs to be used in social media relating specifically to Noteworthy Music Therapy (i.e. NMT’s Facebook page). No patient names nor any identifying information will ever be used with pictures.

Permission for photos/videos:*

I agreeI do not agree

Permission for photos on NMT social media:*

I agreeI do not agree

Thank you again for the opportunity to work with your child and your family. Feel free to contact Jennifer or your therapist at any time with questions, concerns, or feedback, or with any changes in your child’s condition that may affect the ongoing music therapy treatment. Looking forward to a productive therapeutic relationship! Please sign and date below to complete this consent form.

Parent/Guardian Signature*

Date*

Date