Student Information Form

Information Form

Please fill out this form below for your child(ren) to see if music therapy will be beneficial for him/her. Once complete, we will email you with more information.
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent E-mail
example@example.com
Parent Mobile Number
Format: (000) 000-0000.

1. Is the child struggling with emotional expression or regulation?

NOT AT ALL SOMETIMES OFTEN
2. Does the child have difficulty with social interactions?

NOT AT ALL SOMETIMES OFTEN
3. Is there a need to enhance the child's communication skills? If yes, please explain how below:
4. Are these sensory processing issues?

NOT AT ALL SOMETIMES OFTEN
5. Is the child experiencing developmental delays or disabilities?

NOT AT ALL SOMETIMES OFTEN
6. Is the child dealing with stress, anxiety, or trauma?

NOT AT ALL SOMETIMES OFTEN
7. Does the child have trouble focusing or staying engaged?

NOT AT ALL SOMETIMES OFTEN
8. Are there speech or language difficulties? If yes, please explain how below:
9. Has the child shown an interest in music?

NOT AT ALL SOMETIMES OFTEN
10. Have other therapies or interventions been tried? If yes, please explain which one(s) and how have they been implemented.

WELCOME TO SOUNDS OF THE SPECTRUM :)

Thanks for introducing and telling us more about your child. We are very excited that you both are taking this journey into music with us.
Take a Look Inside Hear No Evil Studio in Orange, CA
ABOUT THE PROGRAM:

Class is weekly every Thursday between 3PM-5PM at Hear No Evil Studios in Orange. There will be two music teachers on site to teach lessons with different instruments. Instruments include drums, piano, guitar/bass, and vocals. The first 30 minutes of class will be a group activity and then each student gets 30 minutes with instrument A and then 30 minutes with instrument B. Then the last 30 minutes is free play. The following week will be the same except with different instruments: 30 minutes instrument C first and then 30 minutes instrument D.
COST OF THE PROGRAM:

Cost is $100/class, but if you pay for the month then you'll get a discount ($90/class) which equates to $360 - $450 per month (depending how many Thursdays in that month)
Do You Want to Visit the Studio? Make an Appointment Here:
Which Thursday Would You Like to Start?

MonthDayYear
Date
Should be Empty:

Information Form