In this space, please include any and all information that you feel is important for us to know about the person who will be participating in a Muzique Experience. Regardless of the experience you are signing up for, it is important for your instructor or therapist to know a bit about you so they can plan accordingly. This could include goals, diagnosis, behavioral concerns, medical concerns, allergies, or any other important info we should know about the person who will be participating in an experience.
Please list any favorite artists, songs, genres, etc. that can assist our therapists/instructor in preparing an appropriate and engaging repertoire for the person participating in a Muzique experience.
POLICY:
It shall be the policy of Muzique to abide by the following:
All patients, or parents or guardians of patients, shall telephone to cancel and reschedule appointments when the patient may have one or more symptoms of a contagious disease. This will aid in the protection of the health of the staff, other patients, and family members.
Symptoms: Fever >100 degrees F
Vomiting / Nausea
Open / Draining Lesion
Lice
Chicken Pox
Measles
Productive cough
Impetigo
Conjunctivitis / pink eye
Strep Throat
Diarrhea
COVID-19
Any Other Contagious Disease Not Listed
INFORMED CONSENT FOR IN-PERSON SERVICES: COVID-19 PUBLIC HEALTH CRISIS
If there is a resurgence of the pandemic or if other health concerns arise, Muzique may require that we meet via telehealth/online lessons. You understand that, if Muzique believes it is necessary, we have the right to determine that we return to telehealth/online lessons for everyone’s well-being. If you decide at any time that you would feel safer staying with, or returning to, telehealth/online lessons/services, we
will respect that decision, as long as it is feasible and clinically appropriate. We may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes, including, but not limited to, utilizing telehealth/online lessons.
Your Responsibility to Minimize Your Exposure- To obtain services in person, you agree to take certain precautions which will help keep everyone (you, your therapist/instructor, all families, and other patients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting / returning to a telehealth/online lessons arrangement:
● You will only keep your in-person appointment if you are symptom free.
● You will wear a mask or nose/mouth covering before entering the building and will not remove it until you have left.
● Only the client and a single guardian will come to appointments.
● We may take your temperature before each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of COVID-19, you agree to cancel the appointment and/or proceed using telehealth/online lessons.
● You will wash hands or use alcohol-based hand sanitizer upon arrival
● We will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands).
● Try not to touch your face or eyes with your hands. If either of the client or therapist/instructor does, we will immediately wash or sanitize your hands.
● If a resident of your home tests positive for the infection, you will immediately let us know and we will then resume treatment via telehealth/online lessons for at least 1 week.
Muzique’s Commitment to Minimize Exposure- Muzique’s team has taken steps to reduce the risk of spreading COVID-19 with details listed below. Please let us know if you have questions about these efforts:
● Music Therapist/instructor will wash hands upon arrival to site and use hand sanitizer of 60% or greater concentration. This includes when entering homes, and facilities and after each visit.
● Music Therapist/instructor will sterilize all equipment/ instruments with medical grade wipes used following each session.
● Music Therapist/instructor will minimize the use of instruments that require detailed sanitization.
● Music Therapist/instructor will avoid touching face/eyes, handshakes, personal contact etc.
● Music Therapist/instructor will wear a mask at all times.
● No services will be provided to patients/clients with known potential or confirmed flu/COVID-19 diagnosis (including Persons Under Investigation waiting for results).
The following practice-wide response policies are noted below. This is based on the most conservative measures in order to protect our most fragile clients:
● The therapist/instructor will cancel/reschedule planned sessions if they or anyone in their household exhibits any signs of illness (i.e, fever, cough, runny/drippy nose, congestion, shortness of breath etc.) Both myself/family must be fever free (<100 F) for 24 hrs upon return to work.
● If it’s determined that the therapist/instructor may have been exposed to a potential case of COVID-19, they will cease in person work immediately and self-quarantine until test results are determined. If a test is positive, then self-quarantine and self-monitor for at least 7 days following exposure, per the most current CDC guidelines.
● If any school, family or community agency determines that the therapist/instructor may have been directly exposed, they must notify immediately and the therapist/instructor will self-quarantine and monitor status until patient/client test results are confirmed.
You understand that Muzique is committed to keeping you, our therapists/instructors, and all of our families safe from the spread of this virus. If upon arrival for our appointment, your therapist/instructor or another team member believes that you have a fever or other symptoms, or believes you have been exposed, we will cancel the session. We can follow up with services by telehealth/online lessons as appropriate. If the therapist/instructor has known exposure or tests positive for COVID-19, we will notify you so that you can take appropriate precautions.
Your Confidentiality in the Case of Infection: If you have tested positive for COVID-19, we may be required to notify local health authorities that we have been in contact. If we have to report this, we will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for your visits. By signing this form, you are agreeing that we may do so without an additional signed release.
Your signature below shows that you agree to these terms and conditions.
I agree to abide by the above stated policies:
I have informed myself of the policies, procedures and methods instilled by Muzique, LLC, and consent to the use thereof in providing treatment for/lessons to my child.
For in-home experiences: I understand that if incidents occur within my home, my homeowners insurance is set in place to handle these situations, for example a therapist/instructor tripping on a faulty step, being bitten by my pet, etc. I understand that I am to make the therapeutic/lesson space in my home safe for both my child and the therapist/instructor prior to session times. I also understand that both Muzique, LLC and the instructor/therapist are personally insured for their property and professional selves.
I consent for Muzique, LLC, to provide me with music therapy services. I acknowledge that there is always a risk of injury with any therapy involving physical activities. I agree to accept full responsibility for any physical injuries, and agree to take initiative in communicating any physical or emotional discomfort to the therapist immediately. I consent to care and treatment falling under the practice guidelines of the experience I have chosen to receive.
I acknowledge that it is my responsibility to inform my child's primary care physician of my child’s participation in the Muzique experience(s) I have chosen, if necessary. I voluntarily request that Muzique, LLC provide therapy for/lessons to my child.
I understand that Muzique, LLC wishes to take reasonable steps to maintain the safety and wellbeing of its participants, therapist and all involved. I confirm that I have disclosed all medical conditions of my child that may be affected in any way by the treatment. I acknowledge that I am responsible for updating this release if the medical condition of my child changes.
I acknowledge that I have been given the opportunity to ask questions, if any, concerning the nature and scope of this agreement. I have read the entire agreement and agree to it.
POLICIES:
Upon enrollment and receipt of this session/lesson policy, the student and/or parent/guardian must agree to these terms and understand fully all rules in our studio.
Punctuality & Attendance:
It is very important for students to arrive on time for their scheduled lesson/session. Consistent attendance is vital to success and progression. Sessions and lessons will end at scheduled time, regardless of when they begin. With this in mind, please attend all scheduled lessons/sessions on time and consistently.
Tuition & Payment:
Muzique, LLC offers several different options for your loved ones. For more information, including pricing, please contact us. All services are 45 minutes in length.
Tuition is automatically charged on the first of every month. Tuition costs for each offering can be found upon request, as our prices may change or differ. Our price stays the same per month, even with 5 weeks in a month. With tuition, we guarantee to offer you 4 sessions in the month. There will be a $20.00 charge added to all returned checks/bounced charges. In order to withdraw from our program, we must be notified we must be notified by 2 weeks in advance in order for you to not be charged for the next month and for therapeutic purposes to provide both client and therapist with proper closure. All sessions and lessons will be continuous unless otherwise notified. If enrolled in therapy, please understand that treatment will be ongoing, with a reassessment given only when requested by the parent or case manager, or if the therapist sees fit.
Cancellations:
We require a 24-hour minimum cancellation notice in order for you to be considered for rescheduling. 24-hour cancellation rescheduling is fully at the discretion of the therapist or instructor and is dependent upon the schedule of the therapist or instructor, unless 2+ weeks notice is given, i.e. scheduled vacation. To cancel a session, you need to call YOUR INSTRUCTOR OR THERAPIST and they will then relay the message to Muzique management, noting the time of your call. If more than 2 hours notice is not given or you do not show up to your scheduled appointment, the individual automatically forfeits the lesson, and will be charged. Cancelling or missing a lesson does not reduce or delay payment. No-shows will not be made up under any circumstances. If the instructor/therapist has to cancel a lesson, a make-up will be given within a month of the therapist/instructor's cancellation. There will be no prorating or price adjustment under any circumstances, unless decided by Muzique management in very specific situations.
Absences:
A same-day excused absence is illness of the student or an extreme family emergency. For families with more than one student, only the student who is ill will be excused. Should school be closed, sessions will likely still happen. If there is any doubt, please call your therapist/instructor ahead to verify. Students are required to give two-week notice when they take a vacation. All planned absences should be reported to the instructor or therapist. THERE ARE NO MAKE-UPS FOR GROUPS.
Make-ups:
Make-ups will be arranged if the therapist’s time and space permit; however, the instructor is not obligated. All make-ups must be done within one month of the absence. Make ups will be provided on a first come first serve basis. There are no “make-ups of make-ups”. If the student misses the make-up lesson, the lesson is forfeited. No refunds will be issued for student’s absences. Our goal with your tuition is to provide at least 4 sessions within the month. Anything additional is just a bonus for you! Please keep in mind that make-ups are for therapeutic or practical reasons, not for monetary reasons. Make-ups need to be scheduled at the time of cancellation for a date within a reasonable time frame from the absence. Any questions regarding this, please call Muzique, LLC.
Termination & Refunds:
Although rescheduling is provided (as stated above), credits or refunds are not given for missed lessons. If the student decides to discontinue lessons prior to the completion of the month, no refunds will be given for lessons not taken. If for any reason Muzique, LLC is required to close by mandate or law in the state of New Jersey, all services will be moved online until we can resume services in person.
PRACTICE (for lessons)!!!! :
Daily practice is essential to learning any instrument. The family will need to establish a daily routine for the student that includes practice. At each lesson, the teacher will clearly explain the student's practicing assignments for that week. The teacher will notate the practice assignments. The student is expected to complete the assignments by the next lesson. Parental help may be required if the student is too young to read.
Behavior IN Studio- All students MUST follow all rules of etiquette while in our studio spaces:
1. Treat Everyone; Students, Teachers, Guests, etc. with only the utmost respect.
2. Clean up any trash you bring into the building. Trash bins are located in the art studio, and bathroom. Please no eating in the studios.
3. Take care of all equipment in lobby or in studio space.
4. Have FUN! The arts are all about expressing and finding yourself through exploration, whether structured or improved. So make sure you and your family remember to have fun!
MISSION STATEMENT:
The mission of Muzique, LLC is to provide unique music and arts experiences for anyone and everyone! We aim to serve the community in all different ways including, music, art, drama, and dance. These services will be offered for children and adults, both neurotypical and special needs, in many different forms including therapy, recreational groups, individual services, and performance-based services. This program will help to bring the community together and provide a safe space for children and adults to explore the beauty of the arts. Muzique’s personnel strive to maintain optimal standards of professional practice and exercise professional judgment in the delivery of quality service to each individual served. The personnel adhere to and support the mission, purpose, philosophy, and adopt the Code of Ethics of each profession providing service.• Muzique, LLC will abide by the letter and spirit and spirit of the laws and regulations of the local community, the state and federal governments, with regard to all of its operations.• The Clinic will be managed to provide the highest level of service to both patients and participating medical professionals.• The Clinic acknowledges the intrinsic value of the individual, and pledges itself to behave toward each patient, practitioner, and employee in a manner, which honors and promotes his or her dignity and value as a person and special creation of God.• The Clinic will manage its affairs and resources to ensure a fair and reasonable return to its investors, high value to its clientele, and fair and honorable treatment of its employees and suppliers.• The Clinic will not discriminate in its treatment of any person or group of persons, on the basis of race, gender, national origin, or religious affiliation.
I have read the above and understand and agree to the terms and rules listed:
I, the patient or parent/legal guardian, agree to receive telehealth services. I understand that the Board-Certified health care practitioner is located at an off site location, who is an employee/contractor of Muzique, LLC. A telemedicine service means that the patient’s visit with a Board-Certified health care practitioner at another location (distant site) will happen by using special audiovisual equipment.
Telemental health is live two - way audio and video electronic communications that allows therapists and clients to meet outside of a physical office setting.
*I, for myself or as the parent/legal guardian for the patient, also understand and agree that:
*The same confidentiality protections that apply to in person services also apply to telehealth.
*The information from the telehealth service (images that can be identified as mine or other medical information from the telehealth service) cannot be released to researchers or anyone else without my additional written consent.
*I understand that Muzique, LLC aims to comply with COPPA laws and regulations and that some platforms may collect electronic data beyond Muzique’s control. Permitted platforms include Zoom, doxy.me, and Facetime. Unless a separate consent is given, no other platform should be used.
*I will be informed of any individuals/student therapists who will be present at the originating site and/or a distant site during my telehealth service.
*I can decline the telehealth service at any time without affecting my right to future care or treatment, any program benefits to which I would otherwise be entitled cannot be taken away.
*I understand that in order to receive the highest quality or services, the therapist and/or client may agree to use software that is not typically HIPAA secure, such as Zoom, doxy.me, or Facetime. I agree to use these means of software in order to ensure that I receive the best quality of care via telehealth.
*I understand that telemedicine requires me to have a secure connection to internet access. It is my responsibility to ensure that I am in a private area and will not hold Muzique, LLC responsible for information that may be found on any of my electronic devices. Additionally, if my session is interrupted due to power failure or a faulty connection I can call my therapist directly to re-establish connection and solve the issue.
Additional Information and Informed Consent for Telemental Health Treatment
I understand that telemental health services are completely voluntary and that I can withdraw this consent at any time.
I understand that none of the telemental health sessions will be recorded or photographed.
I agree not to make or allow audio or video recordings of any portion of the sessions.
I understand that the laws that protect privacy and the confidentiality of client information also apply to telemental health, and that no information obtained in the use of telemental health that identifies me will be disclosed to other entities without my consent.
I understand that telemental health is performed over a secure communication system that is almost impossible for anyone else to access. I understand that any internet based communication is not 100 % guaranteed to be secure.
I agree that the therapist and practice will not be held responsible if any outside party gains access to my personal information by bypassing the security measures of the communication system.
I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
I understand that I or my therapist may discontinue the telemental sessions at any time if it is felt that the video technology is not adequate for the situation.
I understand that if there is an emergency during a telemental health session, then my therapist may call emergency services and/ or my emergency contact.
I understand that this form is signed in addition to the Notice of Privacy Practices and Consent to Treatment and that all office policies and procedures apply to telemental health services.
I understand that if the video conferencing connection drops while I am in a session, I will have an additional phone line available to contact my therapist, or I will make additional plans with my therapist ahead of time for re - contact.
I understand a “no show” or late fee will be charged if I miss an appointment or do not cancel within 24 hours of scheduled appointment. I understand credit card or other form of payment will be established before the first session.
I understand my therapist will advise me about what telemental health platform to use and she will establish a video conference session.
I understand that in the event of an emergency, sessions may be held online when appropriate.
