Hope & Harmony NJ, LLC

Music Therapy Inquiry Form

We’re so glad you’re considering music therapy with Hope & Harmony! Please fill out the form below to get started:

Caregiver's first & last name

Phone

Child's first & last name

Child's birthday

Month

Day

Year

Formal diagnosis (if applicable)

Please write N/A if your child doesn't have a formal diagnosis at this time.

The following questions will help us better understand your child’s needs and what you’re hoping to work on through music therapy. Don’t worry if you’re unsure of some answers! We’ll complete a more formal evaluation together once we meet your child.

General areas of functioning you would like to see addressed in therapy

Please select all that apply.

If you answered "Other" above, please specify

Are there any specific goals you'd like addressed in therapy? (i.e. improving articulation of speech, increasing attention span, improving sensory or emotional regulation)

Please write N/A if you don't have anything specific in mind.

Child's musical preferences, such as songs, artists, instruments etc.

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

Please share any other information about your child that may be pertinent to our therapeutic work (i.e. behaviors, motivators, allergies/meds, fears, interests and preferred activities)

Thanks so much for filling this out! We’ll be in touch soon to schedule a discovery call, learn more about your child and family, and explore how we can best support you.

We look forward to connecting with you! 🎶

Please join our waitlist!
Call us today! (908) 839-5145

Hope & Harmony NJ, LLC

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