Facility / Group Intake Form for Music Therapy Services

Glow MT provides group music therapy services led by a board-certified music therapist (MT-BC). Services may include group assessment, music-based interventions, therapeutic singing, movement to music, instrument play, relaxation, songwriting, music-assisted discussion, cognitive and social engagement, emotional expression, sensory support, and other clinically appropriate music therapy experiences.

Group goals and interventions are determined by the MT-BC based on the needs, abilities, safety considerations, and preferences of the participating clients. Glow MT provides services in accordance with applicable laws, professional standards, and the guidelines of the American Music Therapy Association. The facility agrees to provide appropriate space, communication, and support to help services run safely and effectively.

Facility responsibilities. The facility agrees to support group music therapy services by: 1. Providing a safe, clean, and appropriate space for group sessions. 2. Identifying appropriate participants for group services. 3. Ensuring that each participant has appropriate consent or authorization to participate, when required. 4. Informing Glow MT of relevant safety, medical, behavioral, communication, sensory, mobility, or emotional needs that may affect participation. 5. Providing facility staff support during sessions when needed for safety, personal care, behavioral support, transfers, medical needs, or supervision. 6. Remaining responsible for medical care, nursing care, personal care, toileting, feeding, mobility support, medication administration, and emergency response unless otherwise agreed in writing. 7. Communicating schedule changes, facility closures, participant changes, or concerns as soon as possible. 8. Respecting the privacy and dignity of all participating clients. 9. Ensuring facility policies, emergency procedures, and site-specific safety expectations are communicated to the MT-BC before services begin.

Glow MT provides music therapy services within the MT-BC's professional scope of practice. Glow MT does not replace facility staffing, medical supervision, nursing care, behavioral support staff, or emergency services.

Communication and coordination of care. Glow MT values open and professional communication with facility staff, caregivers, and related professionals when appropriate. The facility will identify a primary contact person for scheduling, communication, billing, and coordination of services, and agrees to communicate any relevant updates that may affect group services. Glow MT may communicate general group updates, recommendations, or concerns to the facility contact as appropriate; individual client-specific information will only be shared as appropriate for treatment, coordination of care, documentation, safety, or as required by law.

HIPAA, privacy, and confidentiality. Glow MT is committed to protecting client privacy and confidentiality in accordance with HIPAA standards, when applicable, and all applicable privacy laws. Information shared during intake, communication, group participation, and documentation will be handled with care and used only for appropriate treatment, billing, documentation, coordination of care, safety, or as otherwise required by law.

Confidentiality in group settings. Because group music therapy involves multiple participants, complete confidentiality among group members cannot be guaranteed. Glow MT and the facility will make reasonable efforts to protect the privacy, dignity, and personal information of all participants. Facility staff are expected to support confidentiality and avoid unnecessary sharing of client information during or after sessions.

The facility agrees not to photograph, audio record, video record, or publicly share any portion of music therapy sessions without prior written consent from Glow MT and any required client, guardian, or facility authorization.

Mandatory reporting and safety concerns. Glow MT and its MT-BCs are required to follow applicable mandatory reporting laws. If an MT-BC has reason to suspect abuse, neglect, abandonment, exploitation, self-neglect, or an immediate safety concern involving a child, vulnerable adult, or other protected individual, Glow MT may be required to report the concern to the appropriate agency or authority. Glow MT may also take appropriate action if a participant expresses intent to harm themselves or others. Glow MT is not responsible for investigating or determining whether harm has occurred; reports are made so the appropriate authorities can assess the situation. In an emergency or immediate danger, facility staff and/or caregivers should contact emergency services immediately.

Client rights in group music therapy. Participants have the right to: 1. Be treated with dignity, respect, kindness, and professionalism. 2. Participate in a safe and supportive therapeutic environment. 3. Receive services that consider their needs, strengths, preferences, abilities, and goals. 4. Refuse, pause, or request modification of participation when appropriate. 5. Have their privacy and confidentiality respected within the limits of group services, professional ethics, and the law. 6. Receive reasonable accommodations or modifications when possible. 7. Participate without discrimination, coercion, unnecessary pressure, or judgment. 8. Have concerns communicated respectfully to the appropriate facility contact, caregiver, guardian, or support person when needed.

Scheduling, cancellations, and rescheduling. Services are scheduled by the agreed-upon frequency, session length, and location. The facility agrees to notify Glow MT as soon as possible of schedule changes, room changes, closures, staffing concerns, or other issues. Sessions canceled by the facility may be rescheduled based on the MT-BC's availability; rescheduling is not guaranteed. If the MT-BC must cancel, Glow MT will notify the facility as soon as possible and make reasonable efforts to reschedule when appropriate.

Billing and payment. Billing terms, rates, and payment expectations are agreed upon before services begin. Unless otherwise stated in writing, invoices are emailed on the 1st of each month for services provided the previous month, and payment is due by the following month. Overdue payments may result in services being paused until payment is received or another arrangement is approved by Glow MT.

Documentation and reports. Glow MT may maintain documentation of group services (attendance, general participation, interventions used, goals addressed, observations, and recommendations). Written reports or summaries may be provided upon request when appropriate and agreed upon.

Termination of services. Either party may discontinue services with appropriate written communication; advance notice is requested when possible. Glow MT reserves the right to pause or terminate services determined to be clinically inappropriate, ineffective, harmful, unsafe, or counterproductive, or if the MT-BC feels unable to provide services safely, ethically, or effectively. In safety-related situations, services may be terminated immediately. Outstanding payment for services already provided remains the responsibility of the facility or responsible billing party.

This section gives Glow MT permission to photograph, audio record, video record, and/or share media from group music therapy sessions, when appropriate and authorized. Media may include photographs, audio, video, short clips, written descriptions, or other materials captured during or related to sessions.

Glow MT will make reasonable efforts to protect the privacy, dignity, and confidentiality of all participants and will not share a participant's full name, diagnosis, medical history, or other private identifying information unless separately authorized in writing. Because group sessions may include multiple participants, media may capture more than one client at a time. The facility is responsible for informing Glow MT of any participants who should not be photographed, recorded, posted, or included in shared media. This release does not replace any consent, authorization, or media policy required by the facility, and individual client/guardian consent may still be required when participants are identifiable.

By providing my signature below, I acknowledge that I am an authorized representative of the facility/organization listed in this agreement and have the authority to enter into this agreement with Glow MT on its behalf.

I acknowledge that I have received, read, understood, and agree to the group music therapy policies, procedures, expectations, and responsibilities outlined above, including communication, scheduling, rescheduling, billing, documentation, confidentiality, HIPAA/privacy, mandatory reporting, client rights, facility responsibilities, and termination of services.

I understand that Glow MT provides music therapy services within the professional scope of practice of the MT-BC and does not replace facility staffing, medical care, nursing care, personal care, behavioral supervision, or emergency response procedures. I understand that payment remains the responsibility of the facility/organization or responsible billing party for all services provided, and that any photo/audio/video/social-media release must be addressed through the media section above.