The entire staff at The George Center for Music Therapy, Inc. would like to thank you for choosing us and welcome you to our family.  

It is our goal at The George Center to provide you with outstanding services, support, and communication regarding your family’s needs.  We provide an environment that is encouraging, well-informed, enjoyable, and sincere.  We want you to be an integral and active participant in your child’s therapy and learn how to provide an environment for your child and family that will support his/her development.  We also want you to be involved in establishing goals, treatment planning, home exercises, and discharge planning.  Our intention is to move towards a level of independence within everyone’s abilities.  

Included in our paperwork you will find:
Family/patient information sheet
Consent to treat/medical 
Financial agreement
Permission for exchange of info
Attendance Policy
Permission to leave site
Audiovisual release
Student Observation Release
HIPAA policy

Please read all forms thoroughly so that you are informed about the agreements you are signing, and ask any questions to better help us serve you and your family.  

Additionally, some other pieces of information are requested.

If you are billing insurance, we will need:

Copy of driver’s license
Copy of the front and back of your insurance card
Current prescription from PCP – Must state MT services 1x a week, for 12 months for specific diagnoses

For all patients, we will need:
Most recent OT/ST/PT/Psychological evaluations within the past year
Current Behavioral Intervention Plan
Waiver and/or Grant information (if applicable to your child)

*Please note that these items MUST be received prior to your child’s initial evaluation. They can be faxed to 678-461-8530 or emailed to

We look forward to working with your family.
Thank you,
The George Center Team

12060 Etris Rd., Suite 200
Roswell, GA  30075

Members of the North Fulton Wellness Alliance

Information in this form can be shared with:

Patient’s Name (as appears on insurance card): *

Patient's DOB: *

Patient's Gender:

Parent or Legal Guardian #1 Name: *

Parent or Legal Guardian #2 Name: *

Home Phone Number: *

Cell Phone Number: *

Street Address: *

City, State & Zip Code:

Additional Phone Number:



Primary Physician Name & Address:

Would you like for us to contact your insurance company to check on potential music therapy benefits? *

Insurance Company Name:

Member ID #:

Name of Insured:

Name of Employer & Group #:

Claim Phone Number & Address:

Child's ICD-10 Primary Diagnosis Code (if known):

Are there any other therapists billing this insurance policy?

If yes, please indicate which therapy:

Has your child been approved for the Georgia NOW/COMP Waiver? If so, would you like for us to bill your fiscal agent for your music therapy services?

Have you been approved for funding through a third party source to cover your music therapy services? If yes, please indicate the contact information and instructions on how we are to invoice them.

How did you hear about The George Center for Music Therapy?

What are your child’s favorite toys/activities?

What are your priorities in coming to The George Center?

What are your child’s favorite songs and/or type of music?

Are there any particular artists that your child is interested in?

Has your child had previous music lessons or music therapy elsewhere? If yes, please describe:

Is your child enrolled in any community based programs? i.e. sports teams, church groups, art lessons, etc...

Parent's Names, Age & Occupation: *

Parent's Marital Status:

Sibling Names & Ages:

Is your child adopted?

What is the primary language spoken in your home?

Anything else you would like to tell us about your or family?

At how many weeks was your child born?

Birth Weight:

Were there any complications during the pregnancy or delivery?

If yes, please describe:

Was your child hospitalized after birth?

Does your child have any other medical issues?

Please list any hospitalizations and/or medical procedures your child has received:

Current medications (Please list dosage, frequency & reason for each medication):

Any known allergies? *

If yes, please list and describe expected reactions to allergy and rescue medication protocol.

Does your child require any physical assistance or use assitive equipment? i.e. a wheel chair, walker, etc... *

If yes, please describe:

Does your child communicate verbally?

If no, what is your child's mode of communication? i.e. PIX or ASL, etc...

Are their any medical/behavioral issues that we should be aware of? i.e. seizures, biting, self-injurious behaviors... *

If yes, please elaborate:

Has your child suffered a trauma or recent change in life circumstances?

If yes, please elaborate:

What typically calms/soothes your child? *

Please describe any information we should know regarding your child's gross motor, fine motor, cognitive, sensory, expressive language or social/emotional needs? *

Is your child currently enrolled in school?

If “Yes”, where and days attended:

Does your child receive any services through the school?

If “Yes”, what services?

Does your child have a current Individualized Education Plan (IEP)?

Does you child have a Behavioral Intervention Plan?


This next section contains The George Center Policies and Releases. Please review them carefully. 

If you have any questions or issues with any of the following, please contact us at 678-701-1203. We'd be more than happy to provide further explantion.


This Consent to Treat Agreement is between The George Center for Music Therapy, Inc., and {{answer_6924131}} and {{answer_6925901}}. {{answer_6924131}}and {{answer_6925901}}  are the parents/legal guardians of {{answer_6924063}}, a minor.  I, {{answer_6924131}} and I, {{answer_6925901}} do consent for The George Center for Music Therapy, Inc. to provide {{answer_6924063}},  with Music Therapy services.  I consent to care and treatment falling under the practice guideline of the American Music Therapy Association (AMTA), and the State of Georgia.  I acknowledge that there is always a risk of injury with any therapy involving physical activities.
This agreement constitutes the entire agreement between the parties regarding the matters contained herein.  This agreement may be signed electronically, in counterparts, each of which shall be deemed an original but all of which together shall constitute one and the same instrument. {{answer_6924131}}  and {{answer_6925901}} understand and agree that they are jointly and severally liable to The George Center for Music Therapy, Inc. with regard to all obligations contained within this agreement. *


We thank you for choosing us as your music therapy provider. We are committed to your treatment being successful. The following is a statement of our financial policy that we would like for you to read carefully read and agree to as evidence of your understanding prior to any treatments. 

We must emphasize that our relationship is with you, not your insurance company. We file the insurance claim as a courtesy to our patients . All charges are ultimately your responsibility from the date services are rendered. Our service is not always a covered benefit in all contracts. It is important that you read and understand YOUR health insurance policy and its requirements for coverage. We are not responsible for knowing the requirements of your plan. 

Benefits will be verified upon receipt of your insurance information. You will be made aware of any estimated out-of-pocket expenses prior to the start of services. Information obtained from insurance companies is not always a guarantee of payment. We strive to keep open communication in regards to insurance payment, but it is also important that you review your Explanation of Benefits related to the coverage of our ongoing services as well.

Families will inform The George Center for Music Therapy, Inc. of any changes regarding insurance. Families assign benefits for filed claims to be paid to The George Center for Music Therapy, Inc. Any payment sent directly to the family, intended to cover therapy services provided by The George Center for Music Therapy, Inc., should be given to the front office.

I understand and agree with the above statement: *

The usual and customary rate for services is billed to insurance. If we bill your insurance and you have a deductible, the full amount applied to your deductible will be billed to you. The George Center for Music Therapy, Inc. does not accept Medicaid, therefore families are responsible for all co-pays, co-insurances, and deductible expenses associated with each date of service. Please contact us directly if you are experiencing financial hardship. The George Center for Music Therapy, Inc. accepts cash, check, VISA, MASTERCARD, Discover, and American Express.  There is a $50 fee for all returned checks.  

I understand and agree with the above statement: *

We submit claims to insurance within one month of service dates. If payment has not been received within 60 days, the family will be responsible for the balance. If insurance makes payment, the family will be reimbursed any money that was paid for these services.  

If a family receives a bill that is not paid within 30 days of receipt of invoice, there will be a $20.00 late fee added, and services risk being put on hold. 

I understand and agree with the above statement: *

The George Center for Music Therapy, Inc. will file all insurance claims as an out-of-network provider.  Deeming Waiver and SSI Medicaid are not accepted.  We are not contracted with CMO plans (Amerigroup, Peachstate, or Wellcare). If authorization is required, therapists will submit based on need.  Services will be administered after approval has been obtained. The George Center for Music Therapy, Inc. accepts the Georgia NOW/COMP waiver; however, pre-authorization must be approved.

I understand and agree with the above statement: *

An initial evaluation for music therapy services is $150/hour. Evaluations are an out-of-pocket expense expected at the time of service. An initial evaluation will be needed for all children starting therapy with our facility. Most evaluations will last 1 hour. If a family needs a re-evaluation for insurance or personal reasons, the rate will be $150/hr.  Financial arrangements will be made prior to the time of evaluation.

I understand and agree with the above statement: *

I authorize The George Center for Music Therapy, Inc. to release necessary and pertinent medical information to physicians, case managers, teachers, other therapists and insurance companies as needed for my child.
Approved information includes written documents and/or verbal discussion.

Please note that unless your child's caregiver is listed below, your therapist will not be able to share information regarding your child's session. At any point you would like to add a caregiver's name and permission to share information, please inform the front desk or your therapist to fill out the appropriate form.


Please list names and phone numbers of approved providers/school or caregiver:


Because of frequent no-shows and cancellations, The George Center for Music Therapy, Inc. has a policy that states that we require a 24 hour notice for cancellations.  After a one-time occurrence, a $40 fee will be charged for EACH missed therapy appointment.   We know that sickness occurs; therefore, if you think that your child is sick the night before, please call us and give us notice so we may plan accordingly, and/or contact a family who is on stand by for a make-up session or on a waiting list for an evaluation or services.  

To that end, we require that a current credit card be placed on file at all times. You will be asked to fill out that form at your first session.  We will run the no-show/last minute cancellation fee on the date of expected service. This ensures that our clinicians will still receive payment in full for their time and service in preparation for the missed therapy session. In the event of a cancellation, we will make every effort to reschedule as we want your child to benefit from his/her therapy.   

If your child misses 3 consecutive weeks of therapy, we will make every attempt to hold that slot, but cannot guarantee this with an extended absence.  

The staff at The George Center for Music Therapy, Inc. strives to meet the scheduling needs of every family.  If your therapy time does not work for you, please let us know.  The Board of Health considers the following signs to indicate communicable disease/illness:  
Fever over 100 degrees
Sore throat
Rash/Swelling, Red, or Running eyes

Please be sure your child is symptom free for 24 hours before resuming therapy. Please note that if you bring your child to therapy and he/she exhibits any of the above symptoms, it is at the therapist’s discretion to send them home in order to protect themselves and our other clients from infectious illness.

I understand and agree with the above policy: *

We, {{answer_6924131}} and {{answer_6925901}} , understand that while {{answer_6924063}} is receiving therapy we may leave the premises. However, we will give The George Center for Music Therapy, Inc. a working cell phone number where we can be reached during my absence. In addition, we agree that we will return prior to the end of the end of the session. Late pick-ups may result in additional fees, based on individual situation and frequency.  
We give consent and permission to The George Center for Music Therapy, Inc. for any additional treatment or transportation that may be needed in the event that my child is injured or needs medical attention. Also, we understand that the ability to continue to leave the premises while my child is at therapy is at the discretion of The George Center for Music Therapy, Inc. and/or my child’s therapist.

We hereby release The George Center for Music Therapy, Inc., and any agents or assignees, from any and all claims for damages related to my leaving the premises during my child’s therapy.


Emergency Contact Name & Cell Number: *

Secondary Emergency Contact & Cell Number:

Most of our therapists are booked back to back. Out of respect to the next patient's session, we request that, if you do leave the premises, you return 10 minutes prior to your child's session ending.

I understand and agree with the above statement. *


{{answer_6924131}}  and {{answer_6925901}}, do give permission for {{answer_6924063}} to be photographed by the therapists at The George Center for Music Therapy, Inc.  These photographs will be used for education and training purposes (i.e., clinical supervision, conference presentations), and may be used by The George Center for Music Therapy, Inc. for advertisement purposes (i.e., brochures, magazines, newspapers, social media).  
At no time will the patient’s full name be spoken on the tapes and the patient’s full identity will remain confidential.


The George Center is a learning facility. We often have students and interns shadowing our therapists for educational purposes. 

Please indicate if a student or intern is allowed to observe your child's music therapy session. *




We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect January 20, 2015, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law.

We reserve the right to makes changes in our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice Available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or additional copies of this Notice, please contact us using the information listed at the end of this notice.


We use and disclose health information about you for your treatment, payment, and health care operations.

For example:   
Treatment: We may use and disclose your health information to a physician or other health care provider proving treatment to you.

Payment: We may use and disclose your health information to obtain payment services we provide to you.

Health care operations: We may use and disclose your health information in connection with our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence of qualification of health care professionals, evaluating practitioner performance, conducting training programs, accreditation, certification, licensing, and credential activities. 

Your Authorization: In addition to our use of your health information for treatment, payment or health care operations you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use of disclosures permitted by your authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those describes in this Notice.

To your family and friends: We must disclose your health information to you as described in the Patient Rights section of this Notice. We may disclose your health information to a family, member, friend or other person to the extent necessary to help with your health care or with payment for your health care, but only if you agree that we may do so.

Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, or your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object such uses and disclosers. In the event of your incapability or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your health care. We will also use our professional Privacy Notice Page 2 of 2 judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays or other similar forms of health information.

Marketing Health-related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use of disclose your health information what we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may not disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voice mail message messages, postcards, or letters).   


Access: you have the right to inspect and obtain a copy of your protected health information, with limited exceptions. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing, or other cost incurred by us as a result of complying with your request. Requests for access to your protected health information must be made in writing.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other that treatment, payment, health care operations and certain other activities, for the last 6 years, but not before January 20, 2015. You must make your request in writing. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee responding to these additional requests. You have the right to obtain a paper copy of this Privacy Summary Notice as well as the Full Privacy Notice.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). You must make your request in writing.   

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternate locations. (You must make your request in writing.) Your requests must specify the alternative means or location, and provide satisfactory explanation will be handled under the alternative means location you request.   

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.   

Right to Express Complaints: You have the right to express complains to us and to Secretary of the Department of Health and Human Services if you believe that your privacy right have been violated. If you wish to complain to us, you must do so in writing, and direct your complaint to the Privacy Leader.   


If you want more information about our privacy practices, or have questions or concerns, please contact us.    If you are concerned that we may have violated your privacy rights, or disagree with a decision we made access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services upon request.   

We support your right to privacy of your health information. You will not be penalized in any way if you choose to file a complaint with us and/or with the U.S. Department of Health and Human Services.   

For more information about HIPAA or to file a complaint:

The U.S. Department of Health and Human Services Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201 877-696-6775.
I understand and agree to the George Center for Music Therapy, Inc., Notice of Privacy Practice. *

Date of Acknowledgement:

Thank you for taking time to fill out this very important information. 

We can't wait to make music with your child!

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