Muzique New Client Form

To get started with an experience, complete this form and we will give you a call! If you have any questions, contact us first! 

Parent/Guardian Name *
Parent/Guardian Name
Address *
Cell Phone Number *
Cell Phone Number
Client's Name *
Client's Name
Client's Birthdate *
Client's Birthdate
I choose to receive therapy services through the Muzique and will be responsible for any charges. I have been made aware that Muzique is a cash based practice and I am paying out of pocket. This means that we do not work directly with insurance companies or DDD companies directly (only on an individual basis as requested). Upon request, Muzique provides a monthly receipt that I may turn in to insurance, an advocate, district, or other funder to inquire about reimbursement, but I am ultimately responsible for the payments. Muzique has made me aware of funding options available for my child. I AM AWARE THAT I WILL BE AUTOMATICALLY CHARGED CHARGED ON THE FIRST OF THE MONTH. IF I NEED TO CANCEL OR CHANGE PAYMENT DATE FOR THE NEXT CYCLE, I MUST NOTIFY MUZIQUE BY THE 15TH OF THE MONTH BEFORE. **YOU MUST ENTER A CREDIT CARD TO KEEP ON FILE BUT WILL NOT BE CHARGED UNTIL YOU HEAR FROM US! **If you are receiving services through DDD or another payment form, please fill in 0s (zeros) for the card number and CVV code, and enter a random date.
Name on Credit Card *
Name on Credit Card
CARD REQUIRED UNLESS YOU ARE FUNDED BY AN OUTSIDE SOURCE! Your card will NOT be charged unless you have scheduled an assessment or lesson with Muzique. The card you enter below will be used for all FUTURE charges, including assessments and monthly tuition. Your card will be placed in our secure system and will be protected. After that, all tuition and payments will automatically be charged on the first of the month. **If you are receiving services through DDD or another payment form, please fill in 0s (zeros) for the card number and CVV code, and enter a random date.
Numbers on back of card
Expiration Date *
Expiration Date
(If no day is specified on your card, please just enter "01" in the "DD" spot)
POLICY: It shall be the policy of Muzique to abide by the following: All patients, or parents or guardians of patients, shall telephone to cancel and reschedule appointments when the patient may have one or more symptoms of a contagious disease. This will aid in the protection of the health of the staff, other patients, and family members. Symptoms: Fever >100 degrees F Vomiting / Nausea Open / Draining Lesion Lice Chicken Pox Measles Productive cough Impetigo Conjunctivitis / pink eye Strep Throat Diarrhea Any Other Contagious Disease Not Listed I agree to abide by the above stated policy:
I have informed myself of the policies, procedures and methods instilled by Muzique, LLC, and consent to the use thereof in providing treatment for/lessons to my child. For in-home experiences: I understand that if incidents occur within my home, my homeowners insurance is set in place to handle these situations, for example a therapist/instructor tripping on a faulty step, being bitten by my pet, etc. I understand that I am to make the therapeutic/lesson space in my home safe for both my child and the therapist/instructor prior to session times. I also understand that both Muzique, LLC and the instructor/therapist are personally insured for their property and professional selves. I consent for Muzique, LLC, to provide me with music therapy services. I acknowledge that there is always a risk of injury with any therapy involving physical activities. I agree to accept full responsibility for any physical injuries, and agree to take initiative in communicating any physical or emotional discomfort to the therapist immediately. I consent to care and treatment falling under the practice guidelines of the experience I have chosen to receive. I acknowledge that it is my responsibility to inform my child's primary care physician of my child’s participation in the Muzique experience(s) I have chosen, if necessary. I voluntarily request that Muzique, LLC provide therapy for/lessons to my child. I understand that Muzique, LLC wishes to take reasonable steps to maintain the safety and wellbeing of its participants, therapist and all involved. I confirm that I have disclosed all medical conditions of my child that may be affected in any way by the treatment. I acknowledge that I am responsible for updating this release if the medical condition of my child changes. I acknowledge that I have been given the opportunity to ask questions, if any, concerning the nature and scope of this agreement. I have read the entire agreement and agree to it.
Photo / Video Release *
Muzique occasionally takes photos or short videos for treatment and assessment purposes. Muzique also has a web site that is used for promotion and education. Below is permission or a decline for Muzique to use these photos/videos for educational purposes and legal promotion of the clinic. CHECK ONLY ONE BOX BELOW!
Experience(s) of Interest *
Please select all experiences that you may be interested in! We will call you with more info and you can then let us know what you would like to register for.
MISSION STATEMENT The mission of Muzique is to provide unique music and arts experiences for anyone and everyone! We aim to serve the community in all different ways including, music, art, drama, and dance. These services will be offered for children and adults, both neurotypical and special needs, in many different forms including therapy, recreational groups, individual services, and performance-based services. This program will help to bring the community together and provide a safe space for children and adults to explore the beauty of the arts. Muzique’s personnel strive to maintain optimal standards of professional practice and exercise professional judgment in the delivery of quality service to each individual served. The personnel adhere to and support the mission, purpose, philosophy, and adopt the Code of Ethics of each profession providing service. • Muzique will abide by the letter and spirit and spirit of the laws and regulations of the local community, the state and federal governments, with regard to all of its operations. • The Clinic will be managed to provide the highest level of service to both patients and participating medical professionals. • The Clinic acknowledges the intrinsic value of the individual, and pledges itself to behave toward each patient, practitioner, and employee in a manner, which honors and promotes his or her dignity and value as a person and special creation of God. • The Clinic will manage its affairs and resources to ensure a fair and reasonable return to its investors, high value to its clientele, and fair and honorable treatment of its employees and suppliers. • The Clinic will not discriminate in its treatment of any person or group of persons, on the basis of race, gender, national origin, or religious affiliation. Policies Upon enrollment and receipt of this session/lesson policy, the student and/or parent/guardian must agree to these terms and understand fully all rules in our studio. PUNCTUALITY & ATTENDANCE It is very important for students to arrive on time for their scheduled lesson/session. Consistent attendance is vital to success and progression. Sessions and lessons will end at scheduled time, regardless of when they begin. With this in mind, please attend all scheduled lessons/sessions on time and consistently. TUITION & PAYMENT Muzique offers several different options for your loved ones. Those options are listed below and for more information, including pricing, please contact us ($10 discount for multiple family members/lessons applies to all experiences, with the highest cost being offered at full price and the rest discounted). -Music Therapy 45-Minute Session -Try Me Lessons (Ages 4-10) (20-Minutes #1 Instrument & 20-Minutes #2 Instrument w/ a 5-minute break) -Music Lessons 30-Minute or 60-Minute -Adapted Music Lessons 30-Minute or 60-Minute Tuition is automatically charged on the first of every month. Tuition costs for each offering can be found upon request, as our prices may change or differ. Our price stays the same per month, even with 5 weeks in a month. With tuition, we are essentially providing each of you with about 4 free lessons a year, if attendance is consistent and make ups are not required. There will be a $20.00 charge added to all returned checks/bounced charges. In order to withdraw from our program, we must be notified we must be notified by 2 weeks in advance in order for you to not be charged for the next month and for therapeutic purposes to provide both client and therapist with proper closure. All sessions and lessons with be continuous unless otherwise notified. If enrolled in therapy, please understand that treatment will be ongoing, with a reassessment given only when requested by the parent or case manager, or if the therapist sees fit. CANCELLATIONS We require a 24-hour minimum cancellation notice in order for you to be considered for rescheduling. 24-hour cancellation rescheduling is fully at the discretion of the therapist or instructor and is dependent upon the schedule of the therapist or instructor, unless 2+ weeks notice is given, i.e. scheduled vacation. To cancel a session, you need to call YOUR INSTRUCTOR OR THERAPIST and they will then relay the message to Muzique management, noting the time of your call. If 24-hour notice is not given, the student forfeits the lesson, and will be charged. Cancelling or missing a lesson does not reduce or delay payment. No-shows will not be made up under any circumstances. If the instructor/therapist has to cancel a lesson, a make-up will be given within a month of the therapist/instructor's cancellation. There will be no prorating or price adjustment under any circumstances, unless decided by Muzique management in very specific situations. ABSENCES A same-day excused absence is illness of the student or an extreme family emergency. For families with more than one student, only the student who is ill will be excused. Should school be closed, sessions will likely still happen. If there is any doubt, please call your therapist/instructor ahead to verify. Students are required to give two-week notice when they take a vacation. All planned absences should be reported to the instructor or therapist. THERE ARE NO MAKE-UPS FOR GROUPS. If a group/class does not have coverage in the absence of a therapist/instructor and the class/group must be cancelled, a credit will be added to your account. MAKE-UPS Make-ups will be arranged if the therapist’s time and space permit; however, the instructor is not obligated. All make-ups must be done within one month of the absence. Make ups will be provided on first come first serve basis. This is why we already give students 4 free lessons a year. There are no “make-ups of make-ups”. If the student misses the make-up lesson, the lesson is forfeited. No refunds will be issued for student’s absences; however, a credit will be issued for a teacher absence if the teacher is unable to schedule a make-up on his or her end. Our goal with your tuition is to provide at least 4 sessions within the month. Anything additional is just a bonus for you! Please keep in mind that make-ups are for therapeutic or practical reasons, not for monetary reasons. Make-ups need to be scheduled at the time of cancellation for a date within a reasonable time frame from the absence. Any questions regarding this, please call Muzique. TERMINATION & REFUNDS Although rescheduling is provided (as stated above), credits or refunds are not given for missed lessons. If the student decides to discontinue lessons prior to the completion of the month, no refunds will be given for lessons not taken. PRACTICE (FOR LESSONS)!!!! Daily practice is essential to learning any instrument. The family will need to establish a daily routine for the student that includes practice. At each lesson, the teacher will clearly explain the student's practicing assignments for that week. The teacher will notate the practice assignments. The student is expected to complete the assignments by the next lesson. Parental help may be required if the student is too young to read. BEHAVIOR All students MUST follow all rules of etiquette while on our premises: 1. Treat Everyone; Students, Teachers, Guests, etc. with only the utmost respect. 2. Clean up any trash you bring into the building. Trash bins are located in the art studio, and bathroom. Please no eating in the studios. 3. Take care of all equipment in lobby or in studio space. 4. This space does not belong to Muzique so please treat it as a whole with respect so we can continue to use it! 5. Have FUN! The arts are all about expressing and finding yourself through exploration, whether structured or improved. So make sure you and your family remember to have fun! I have read the above and understand and agree to the terms and rules listed.

Want to know more about creative arts therapies and ready to see how they can benefit you?