Individual Session Form

Thank you for choosing Life Tunes Music Therapy! Please fill in your details in the form below. 谢谢你选择Life Tunes Music Therapy！请在以下的表格填写您的资料。

Assessment Fee: RM200

Please kindly complete the form and payment in order to secure an appointment.

Payment details:
Life Tunes Music Therapy
Public Bank 3229371935

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Full Name *

Gender 性别 *

Male 男
Female 女

Email *

Preferred language 语言 *

English 英文
Mandarin 中文

Contact Number 联络号码 *

Ethnicity 种族 *

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Marital Status 婚姻状况 *

Single 单身
Married 已婚
Divorced 离婚

Date of birth 客户的生日日期 *

Religion 宗教 *

Occupation 职业 *

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Home Address 地址 *

Home Address 地址 (copy)

Preferred way of contact 联络方式 *

Email 电邮
Whatsapp
Call 电联

Do you have any musical background? (If yes, please explain) 你有任何的音乐训练/背景吗？如果有，请解答。 *

What's your preferred style of music? 请写下你喜爱的音乐风格 *

What is your reason in receiving music therapy? 你接受音乐治疗的目标是什么？ *

Have you received therapy/ counseling before? If yes, please explain. 您曾经接受过其他治疗/辅导吗？如果有，请解答。 *

What's your medical history? 您有任何的病史吗 *

Are you currently on any medication? If yes, please state. 您目前正在服用任何药物吗？如果有，请说明。 *

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Name of Emergency Contact 紧急联系人名字 *

Relationship with Emergency Contact 与紧急联系人的关系 *

Emergency Contact's Number 紧急联系人联络号码 *

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Availability for session(s): Please select all that apply (All times are in Malaysian timezone) 请选择想要接受治疗的时间（注：所有的时间都在马来西亚时区） *

Monday
Tuesday
Wednesday
Thursday
Friday

Monday Preferred Time

09:00am-12:00pm
1:00pm-5:00pm

Tuesday Preferred Time

09:00am-12:00pm
1:00pm-5:00pm

Wednesday Preferred Time

09:00am-12:00pm
1:00pm-5:00pm

Thursday Preferred Time

09:00am-12:00pm
1:00pm-5:00pm

Friday Preferred Time

09:00am-12:00pm
1:00pm-5:00pm

Payment Prove *

Click or drag a file to this area to upload.