HERO MUSIC THERAPY PROGRAM
Pre-Interview Questionnaire
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Male
Female
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Preferred Contact Method
*
Phone
Email
Text (Non-sensitive updates only)
Emergency Contact
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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SECTION 2 - Military Service
Branch of Service
Army
Navy
Air Force
Marine Corps
Coast Guard
Space Force
Rank at Time of Separation
Please Select
E-1
E-2
E-3
E-4
E-5
E-6
E-7
E-8
E-9
O-1
O-2
O-3
O-4
O-5
O-6
O-7
O-8
O-9
O-10
W-1
W-2
W-3
W-4
W-5
Character of Discharge (You will be asked for a DD-214)
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SECTION 3 - Mental Health & Support
(This section helps us determine program fit. Please answer only what you are comfortable sharing.)
Have you been clinically diagnosed with PTSD?
Yes
No
Unsure/Evaluation in progress
Are you currently receiving mental health care?
Yes
No
If Yes, what type?
Therapy
Psychiatry
VA Mental Health
Support Group
Other
Do you have a support system (family, friend, partner, therapist)?
Yes
No
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SECTION 4 – Music Background
Do you have previous musical experience?
Yes
No
If yes-please describe (Instrument, years played, self-taught, etc.)
Which musical areas are you most interested in for your sessions? (Check all that apply)
Piano
Guitar
Voice/Vocal Coaching
Drums/Percussion
Songwriting
Digital Music Production
Music Appreciation/Listening Therapy
Not Sure yet
Do you have access to the instrument you want to use for your sessions?
Yes
No
What are your preferred music Genres/Artists?
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SECTION 5 – Therapy Preferences
Do you prefer your sessions to be:
In-person
Remote/Virtual
Either is fine
Ideal session times (check all that apply):
Morning
Afternoon
Evening
Weekends
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SECTION 6 – Additional Information
What are your goals for joining the Hero Music Therapy Program?
Is there anything you would like us to know before your interview?
How did you hear about our program?
Please verify that you are human
*
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