Rejoice Music Therapy Informed Consent & Conduct form

I attest that I have voluntarily entered into treatment &/or give my consent for the minor under my legal guardianship mentioned above, to enter into treatment at Rejoice Music Therapy. I consent to treatment provided by a board certified music therapist or student/intern in collaboration with their board certified supervisor. Rights, risks & benefits associated with treatment have been explained to me.*

I agree to treat all others & any property with respect & courtesy at all times while visiting or participating in Rejoice Music Therapy Programs. *

I agree to refrain from the following while visiting or participating in Rejoice Music Therapy programs or sessions: language or communication that may be considered foul or vulgar; threats or intimidation of any kind; deliberate damage to property or others. Rejoice Music Therapy reserves the right to exclude the use of any material (including digital, spoken/voiced, written, etc.) possibly considered offensive, hurtful, abusive, foul, or profane. *

I understand that therapy may be discontinued at any time by either party & that a client may be terminated involuntarily, if: A) the client displays physical violence, verbal abuse, carries weapons, or engages in illegal acts at the office/clinic, &/or B) the client refuses to comply with rules of conduct, fails to make payment or payment arrangements in a timely manner, or repeatedly fails to keep appointments without reasonable cause & explanation.*

I understand that clients may appeal a termination via a discussion with owner & staff & may re-apply for enrollment. Rejoice Music Therapy encourages a discussion to ensure joint resolution.*

I understand that information regarding me and my treatment will be kept confidential UNLESS one of the following applies:

• You, the client, or someone else is in danger, or someone is involved in abuse/neglect/exploitation of a minor or elder.

• The therapist is required by court, administrative order, or subpoena to reveal information.

• You sign a form granting permission to release information to a specific party.

*