Hope & Harmony NJ, LLC

DDD Adult Music Inquiry Form

Caregiver's first & last name

Participant's first & last name

Participant's birthday

Month

Day

Year

Phone

Address

Name of Support Coordinator

Email of Support Coordinator

If interested in 1:1, please specify your Mon-Sat availability

If interested in a group, please specify which one:

Wednesdays at 5p (ages 25-35)

Saturdays at 12:30p (ages 18-25)

The following section will give us insight on the participant's interests, strengths, and challenges for placement purposes.

Formal diagnosis (if applicable)

Please share general interests of the participant (i.e, hobbies, favorite foods, special skills, preferred activities, etc.)

Please list any challenges the participant may be facing (i.e, communication skills, anxiety, motor limitations, vision/hearing impairments, unwanted behaviors, etc.)

What are the participant's musical preferences, such as favorite songs, artists, and instruments?

Please write N/A if you are unsure. Don't worry, we'll figure it out!

Please share any other information about the participant that may be pertinent to our group work (i.e. motivators, allergies/meds, fears/triggers)

Thank you so much for taking the time to fill out this form. We will reach out shortly to discuss everything in more detail.

We are accepting new clients
Call us today! (908) 839-5145

Hope & Harmony NJ, LLC

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