Referral Form

By completing this form, you give the MTAO permission to send out the details provided to our members. If you have any further questions or concerns, please feel free to contact us via email at info@musictherapyontario.com.

Contact Information

Name(Required)

Email Address(Required)

Phone

Geographical Location:(Required)

If you are willing to travel, please indicated other locations here:

Client Information

Are you looking for music therapy for yourself?(Required)

Yes

If no, what is your relationship to the client?

Client Name

Client Age

Diagnosis

Reason for Referral(Required)

What type(s) of music therapy services are you interested in?

Group

Individual

In Person

Virtual

How did you find out about music therapy?