Glow MT New Client Intake

Please share the days/times that work best. We will work to accommodate your schedule within our abilities. Note: Fridays are reserved for reschedules and MT-BC office hours; sessions can be requested as needed.

Glow Music Therapy, LLC ("Glow MT") provides music therapy services in accordance with applicable state and federal laws, professional standards, and the guidelines set forth by the American Music Therapy Association, Inc. (AMTA). Services may include assessment, individualized treatment planning, direct music therapy sessions, consultation, communication with caregivers or related professionals when appropriate, documentation of services, clinical and financial recordkeeping, and timely reports when requested or required.

Please read through these policies carefully. By beginning or continuing services with Glow MT, it will be understood that you have reviewed, understood, and agree to these policies unless you contact us with questions or concerns.

Mandatory reporting. Glow MT and its music therapists 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 make a report to the appropriate agency or authority. Glow MT may also take appropriate action if a client expresses intent to harm themselves or others. Glow MT is not responsible for investigating or determining whether abuse or harm has occurred; reports are made so the appropriate authorities can assess the situation.

Billing. Glow MT will send invoices by email on the 1st day of each month for services provided during the previous month. Payment is due within fourteen calendar days from the date the invoice email is sent. Payments not received within fourteen calendar days will be considered overdue and may result in services being paused until payment is received.

Missed sessions / rescheduling. There is no last-minute cancellation fee. However, any session canceled within 24 hours of the scheduled time is not guaranteed to be rescheduled that week. Sessions canceled at least 24 hours in advance may be rescheduled based on the therapist's availability. No fee is added for arriving late; sessions must still end at the originally scheduled time.

Sickness. Clients should not attend sessions when actively ill. Anyone with a fever of 100°F or higher must be fever-free for at least 24 hours before attending. Individuals with other symptoms (runny nose, sore throat, persistent cough) may be asked to reschedule at the MT-BC's discretion.

Frequently missed appointments. If a client cancels more than three sessions in a row for reasons other than illness, vacation, or previously discussed circumstances, the MT-BC will initiate a conversation about whether services remain appropriate and whether services may need to be paused or terminated.

Termination / discharge. Services may be discontinued when goals are met, the client no longer benefits, services are clinically inappropriate, attendance prevents consistent treatment, funding is unavailable, or either party ends services. Clients/guardians may discontinue at any time with appropriate communication; outstanding payments remain the client's responsibility. In non-emergency situations Glow MT provides a three-week notice when possible; safety-related terminations may occur immediately. A written discharge summary is provided within seven days of discharge.

Client rights & responsibilities. Clients have the right to be treated with dignity and respect; receive individualized services in a safe, non-discriminatory environment; ask questions; participate in treatment planning; refuse or modify interventions; receive clear communication about fees, scheduling, and confidentiality; privacy within the limits of the law and mandatory reporting; request progress updates and accommodations; discontinue services; seek a second opinion; and share concerns or complaints. Clients and Glow MT are jointly responsible for consistent attendance, prompt communication, confidentiality, and respectful, professional communication.

HIPAA & privacy. Glow MT protects each client's privacy and confidentiality in accordance with HIPAA (when applicable) and all applicable privacy laws. Information is used or shared only for appropriate treatment, billing, documentation, coordination of care, or as required by law.

Telehealth. Some services may be provided via digital platforms (e.g. Zoom). Glow MT takes reasonable steps to protect privacy, but digital communication may carry additional privacy risks. If a virtual session is recorded, it will be discussed in advance and only with appropriate consent, unless required by law or for safety.

Terms of agreement. This agreement becomes effective when signed by both parties. Either party may terminate services at any time with appropriate communication. Glow MT is entitled to payment in full for all services provided prior to termination.

Glow MT may request permission to take photographs, audio recordings, and/or video recordings during sessions. Any media may be used for educational, professional, or social media purposes unless otherwise discussed and authorized. Glow MT will protect the client's privacy and dignity; the client's name, diagnosis, or private information will not be shared unless separately authorized in writing.

Giving or refusing permission will not affect the client's ability to receive services. You may revoke this authorization at any time in writing; revocation applies to future use but may not apply to materials already shared.

Music therapy services may be paid for through private pay or, when eligible, through the FES Step Up For Students Scholarship. Private pay rates are $55 for 30 minutes and $95 for 50 minutes; scholarship rates are $60 for 30 minutes and $110 for 50 minutes.

By providing my signature below, I acknowledge that I have received, read, understood, and agree to follow the Policies and Procedures, Client Rights and Responsibilities, and Acknowledgement and Consent documents provided by Glow MT. I authorize Glow MT to provide evaluation and/or music therapy treatment services.

If I am signing on behalf of a client, I confirm that I am the client's parent, legal guardian, or authorized representative with authority to provide consent. I understand that participation does not guarantee a specific outcome, that there may be minimal risk of injury, and that confidentiality may be limited by legal, ethical, or safety responsibilities including mandatory reporting. I understand I may revoke consent in writing at any time, and that revocation does not remove responsibility for payment of services already provided.