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
