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Referral Form

FOR NEW REFERRALS SUBMITTED DEC 2024 TO MARCH 2025:

Our Admin & Director will be out on maternity leave from Dec. 20th 2024 to the end of March 2025.  A team member will reach out to you once we receive your referral (see form below) and begin placements again approximately in April 2025. Thank you for your patience during our team's growth and life transitions. 

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Thank you for taking the time to fill out our Referral Form.  We are so glad you are here!  

 

Once completed, we will review your information and reach out for an intake phone call to learn if we will be a great fit and to answer any questions you may have.  We will be in touch soon!

*Please note: Due to high demand, we currently have limited availability.  If we're unable to place you at this time, we will provide some options for you (e.g. waitlist or refer you to other providers).

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If you have any questions about services or you have not received a placement confirmation within 1-2 months, please reach out to us at admin@alliancemusictherapy.com or call 612-584-0940.  

 

Thank you for your referral and we look forward to connecting with you soon!

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*If you are a BCBS Care Coordinator, please do not use this form and email us at admin@alliancemusictherapy.com if you are having difficulty accessing the BCBS Referral Form through the BCBS portal.  Thank you.​

ALLIANCE MUSIC THERAPY REFERRAL FORM
Client Information
Location/Living Arrangement
Interested Service Type (check all that apply)
Is the client currently on a waiver?
Guardian/POA Information
Best way to communicate
Referral Information

Please note: If you are submitting personal identification or medical information to us on this website, we will maintain its confidentiality and use it only for the purposes of receiving services at Alliance Music Therapy.  We will not transfer the information to any third party without a release of information and will remove or destroy the information upon your request.  By clicking 'Submit,' you agree and acknowledge our Privacy Policy.

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