Client Name *

First Name

Last Name

Date of Birth *

They will receive something special in the mail each year for their birthday!

MM

DD

YYYY

Parent/Guardian Name (if applicable)

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

What would you or your child like to gain from music therapy? *

Check all that apply.

Improve communication skills

Increase social interaction

Develop emotional expression

Reduce anxiety or stress

Improve motor coordination

Support academic or cognitive skills

Enhance memory or focus

Other (please describe)

Preferred Session Length *

25 Minutes Weekly

50 Minutes Weekly

Preferred Session Location *

In-Studio Sessions in Land O Lakes/Lutz

In-Home Sessions in Tampa, Wesley Chapel, Lutz, Land O Lakes, Odessa, Carrollwood areas.

Virtual Sessions Anywhere

Has the client had any prior music therapy or music instruction? *

Yes

No

Does the client enjoy music?

Yes

No

Have you followed @thehudsonmusicstudio on Facebook/Instragram/YouTube yet?

This is a great source for up-to-date info and client success stories!

Yes

No, not on social media.

Are you a Step Up For Students scholarship recipient? *

Sessions can be funded by the SUFS scholarship program for clients with unique abilities.

Yes

No

I have read and agree to the Hudson Piano Studio Policies and Procedures *

YES

NO

Date *

MM

DD

YYYY