“Staying Sharp: Music Therapy Group for Aging Adults”Application for Online Group Name of Applicant * First Name Last Name Applicant Date of Birth * MM DD YYYY Your Name (if different than applicant) First Name Last Name Relationship to Applicant Email * Phone * (###) ### #### Applicant Residence Address * Address 1 Address 2 City State/Province Zip/Postal Code Country What is the level of independence of the applicant's living situation? * Select one... Lives Independently Requires Some Assistance for Activities of Daily Living Requires full-time Care Does applicant have a medical/mental health diagnosis of ANY KIND? If no, type of"No." If yes, include all diagnoses in textbook below. Also include SUSPECTED diagnoses. * How long do you hope to have music therapy services? What do you hope applicant will gain by attending a music therapy group? How did you hear about us? Option 1 Option 2 Is there anything else you would like us to know? Thank you!
