REGISTER FOR ONLINE SERVICES Register for Online Services Name Birthdate Email Phone Number Address Parent or Guardian Name (If applicable, if not, enter N/A) Parent/Guardian Address Parent/Guardian Phone Parent/Guardian Email Select one or more services that you are interested in: Select one or more services that you are interested in: Online Music Enrichment Music Teletherapy Counseling (Teletherapy) Counseling (Office) Preschool Music Enrichment Group (Facebook Live) School Age Music Enrichment Group (Facebook Live) FREE Discovery Call Would you like to request a specific therapist? Would you like to request a specific therapist? Yes No If yes, what is their name? What is your preferred mode of communication? What is your preferred mode of communication? Email Phone Call Is there anything else you would like to communicate? Submit