Let’s play together! Mother's Name * First Name Last Name Father's Name * First Name Last Name Family Email * Phone (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Names and Ages of Children Participating: * The program tuition covers the entire family, and all children are automatically registered in the children's musical program. Please list the full names and ages of all who wish to participate in the program. What draws you to this program? * What is your family's current relationship with music? * Playing (1 or more family members) Listening Dancing Desiring to play Just curious! Little to no musical energy at this time Has your family done any kind of therapy together before? * (This includes traditional therapy, play therapy, or any other form of therapy that involves more than one member of the family). Yes No We have done therapy work, but not as a family, only individually Have you or your children done musical lessons before? * Yes, myself (parent) Yes, one or more child(ren) No How would you describe the emotional/relational atmosphere in your home right now? * Lovely Strongly Disagree Disagree Neutral Agree Strongly Agree Generally smooth Strongly Disagree Disagree Neutral Agree Strongly Agree Parve Strongly Disagree Disagree Neutral Agree Strongly Agree Underlying stress Strongly Disagree Disagree Neutral Agree Strongly Agree Overtly stressful Strongly Disagree Disagree Neutral Agree Strongly Agree Volatile Strongly Disagree Disagree Neutral Agree Strongly Agree Which of these have been/currently are something you are dealing with in your family unit? * Anxiety ADHD Familial Stress Addiction Recovery Sibling Rivalry Tech Overload Emotional Regulation Challenges Intergenerational Trauma Overreactions (parents or children) Chronic Busyness Lack of Creativity Seeking Spiritual Nourishment Is there anything else you'd like to add? Throughout this program and beyond, what are you hoping for within your family unit? * Freedom from Anxiety Increased Focus Co-regulation Increased Communication Stronger Sibling Relationships Technological Relief Emotional Regulation Intergenerational Connection Proactivity and Cohesive Goal Achievement Increased Cleanliness and Home Organization More Playfulness Renewed Spiritual Direction and Purpose More Smiles Appreciation of Quiet Increased Joy Is there anything else you'd like to add? Which musical instruments do you currently have in your home? * Piano/Keyboad Electric Guitar Acoustic or Classical Guitar Flute Drum Set Clarinet Harmonica Trumpet Violin Ukelele Handpan Other: Your program package includes one musical instrument that is sent to your family home. Which of these do you prefer? * Basic Handpan Basic Native Flute Basic Harmonica Basic mini-Guitar Ready to apply? * Ready! Got it! After review, you will receive an email with your next steps. See you soon!
