New Patient/rockSTAR Sign-Up Form (Salesforce)

New Patient/rockSTAR Sign-Up
Wherever you are, in-hospital or at-home, we are here to support you. Sign up today to receive a VIP ALL-ACCESS PASS to be a part of as many programs as you want or need. From 1:1 Music Therapy Sessions, Weekly Group Music & Art Therapy Sessions, rockSTAR Song Requests, and Livestream Performances with special shoutouts from stage, we are here to provide ongoing support and cheer for you! Open to all-ages, whole-family care & free for all patients and families.
By checking this box I certify that I am at least 18 years of age or am the parent or legal guardian of the person listed on this form.

New Patient/rockSTAR Sign-Up
rockSTAR Name

First NameLast Name
rockSTAR Parent/Guardian Name

First NameLast Name
Relationship to the rockSTAR
rockSTAR Contact Email
example@example.com
Confirm Email
example@example.com
Phone Number
Format: 1 (000) 000-0000.
Parent/Guardian Phone Number
Format: 1 (000) 000-0000.
Parent/Guardian Email
example@example.com

City
State
Country
Is the referred rockSTAR living with an acute or chronic illness? Please describe:
Treatment Facility
rockSTAR DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Gender (optional)
Would you be interested in Sibling and Family Support Services?
Would you be interested in a Virtual Music Therapy Session?
Favorite Songs/Artists?

Anything else you'd like us to know? Comments/Questions?
Are there any other programs you're interested in?
Send us a photo of yourself to share with our bands/artists!

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May we share your photo with our artists and publicly (website/social media, etc)
If Yes, what is your social handle(s) so we can tag you?
How did you hear about us?
Tell us how you heard about us...

Rules of Conduct and Participation

Welcome. We are so glad you’re here. Our programs are intended to be safe, supportive, and empowering spaces. To help create a respectful and healing environment, we ask everyone to uphold these community guidelines:

1. This Is a Safe Space: What is shared here, stays here. Everyone should be free to show up authentically without fear of judgment, criticism, or unwanted advice. We honor each other’s stories, struggles, joys, and journeys with compassion and care.

2. Use Language That Supports the Space: This is a place to be heard, comforted, and understood. Honest sharing (including difficult feelings, frustrations, and challenges) is welcome, but please be mindful of how your words and behavior affect others.

Profanity, inappropriate language, and offensive or disrespectful comments are not acceptable. It’s okay to talk about hard things, but repeatedly focusing on complaints or negativity in a way that disrupts or brings down the group is not appropriate. Our goal is to be honest about what we’re going through while moving toward hope, connection, and encouragement.

3. This Is a Peer Support Program: This group creates connection, encouragement, and community through shared experience. Participation is voluntary and does not constitute professional mental health treatment. Because the group is not led by a certified mental health professional, we cannot guarantee therapeutic or clinical outcomes. Please seek professional care when needed.

While rockSTARS often support one another, there is never an expectation or requirement to do so. Everyone is navigating their own challenges. Simply showing up, in whatever capacity you can, is enough.

4. Respect Privacy & Confidentiality: Personal experiences, health information, and emotions shared here should be treated with care and confidentiality. Without clear permission:
- Do not repeat or discuss what others share outside the group.
- Do not name or identify participants publicly or online.
- Do not share details that could reveal someone’s identity or private information.
- Do not record, photograph, or livestream any part of the meeting.
5. Consent Matters: Do not share another participant’s contact information (including social media, phone numbers, or email) without explicit permission. Do not assume someone is comfortable with contact outside the group. Always ask first.

6. Speak From Your Own Experience: Use “I” statements and stay grounded in your own story. We don’t give unsolicited advice. If you’d like to offer support or perspective, ask if it’s welcome first.

7. Be Present and Listen Deeply: Give others space to speak without interruption. Set aside distractions and help create an environment where everyone feels seen, heard, and valued.

8. Judgment Has No Place Here: We come from different backgrounds, beliefs, identities, and experiences, and we value those differences. Disrespectful, discriminatory, or harmful language or behavior will not be tolerated.

By participating in Melodic Caring Project programs, you acknowledge these guidelines and the nature of this peer support space. If you disregard these guidelines you may be asked to leave. Thank you for helping us create a community where healing, connection, and music can thrive.
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