Music Therapy Agreement Form Client's Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Parent/Guardian (if minor client) First Last Address(Required) Street Address Address Line 2 City ZIP Code Email Address(Required) Email Address Confirm Email Address Phone Number(Required)Payment Information(Required) Expiration Date(Required) Month Year Security Code(Required) Cardholder Name(Required)(as it appears on your card) Consent(Required)Music Therapy Services Consent and Payment Agreement I hereby consent to engage in music therapy services provided by Rachel Rambach. I understand that music therapy involves a range of music-related activities designed for therapeutic benefits, and I agree to participate in these activities as part of my treatment plan. Payment Policy: I authorize Rachel Rambach to charge my credit card for payment of music therapy services. I understand that my credit card will be charged on the day of each service provided. Cancellation Policy: I acknowledge that a 24-hour advance notice is required for the cancellation of any scheduled music therapy session. If I fail to provide a 24-hour notice, I understand that I will be responsible for the payment of the full fee for the missed session. By signing below, I confirm that I have read, understood, and agree to the terms and conditions outlined in this consent and payment agreement. I consent to these terms. Δ
