Children's Music Fund- Music Therapist Application

Children's Music Fund (CMF) is a 501(c)(3) non-profit organization that provides musical instruments and music therapy to children with chronic conditions and life-altering illnesses, and supports research on the effects of music therapy. We match eligible children (infant-young adult) with individuals from our network of pre-screened, board-certified music therapists for up to ten fully-funded, weekly one-hour sessions. Network therapists do not work for CMF but are in independent practice. We do, however, ask that all network therapists participate in regular reporting on clients referred by CMF. Thank you for your interest in joining our network of music therapists. Once we receive your electronic application, should we have space for additional therapists, we will contact you to set up an interview. Otherwise, we will keep your application on file for future openings.

Bachelors Degree/Year Awarded:
Masters Degree/Year Awarded:
Board Certification Number:
Board Certification Expiration Date:
Other Trainings and Certifications:
Home Address:
Can Home Address be Shared with Clients:
Business Address if Different from Home:
Can Business Address be Shared with Client:
Can Phone Number be Shared with Clients:
Can Mobile Number be Shared with Clients:
Can E-mail Address be Shared with Client:
Permission to Work in US:
Drivers License Number:
Social Security Number:
Date of Birth:
Ever been convicted of a felony?
Description of Felony:
Have professional liability insurance?
Insurance Provider and Policy Number:
Prior Employment 1:
Can we contact this employer (1)?
Prior Employment 2
Can we contact this employer (2)?
Prior Employment 3
Can we contact this employer (3)?
Additional References:
Preferred populations to serve:
Preferred ages to serve:
Populations prefer not to work with:
Interested in borrowing Instruments?
Preferred location to see clients:
Preferred geographical areas to serve:
Miles prepared to travel:
Provide therapeutic music lessons?
Standard fee or sliding scale?
Typical Hourly Fee:
Approach to Music Therapy:
Instrument Skills:
Instrument Skills Other:
Type of Instruments:
Music Recording Experience:
Other Applicable Skills:
Accuracy of Information Signature:
Accuracy of Information Date Signed:
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