If you have received a link via email with instructions to complete this form, you should have also received a copy or link of a photo or video of your child in action in his or her music therapy session. Please review the video clip contained in that email. If you are comfortable with having So.i.Heard Music Therapy share this photo or video, please complete the form below. After you submit, we will send you an electronic copy of the agreement for your own records.

You are being sent this inquiry because something your child did in his or her session will help other parents and clients understand what music therapy is and what So.i.Heard provides. By sharing real-life client videos, we can help more familes get set up with some awesome resources. However, as our valuable client, your comfort and privacy are most important to us. So, if you do not feel comfortable with us sharing the photo or video in question, let us know, and we will be happy to continue to keep it private.



My Name *
My Name
My Child's Name *
My Child's Name
Date *
Media Agreement *
By checking this box, I hereby agree to allow So.i.Heard Music Therapy to share the photo or video in question that includes my child. So.i.Heard will not share my child's name or other personal information along with the photo or video. I give So.i.Heard permission to use the photo or video on their website, social media accounts, and/or in print.