個別治療報名

參加者姓名　Participant's Name

治療選項 Therapy Options

轉介原因 Reasons for Referral

社交訓練 Social skills training

改善/維持專注力 Promote/maintain concentration

情緒及減壓 Emotion support and stress relief

言語問題，如咬字和失語症 Speech problems, e.g. pronounciation & aphasia

改善/維持動作及協調 Improve/maintain motor skills & coordination

改善/維持認知能力，如記性 Improve/maintain cognitive ablities e.g memory

其他 Others （請於下方說明 Tell us more below）

補充資料/ 疑問　Additional Note / Questions

聯絡人　Contact Person

聯絡電話　Contact Number

電郵　Email

我同意香港音樂治療有限公司的職員以電話、Whatsapp或電郵與我聯絡。

I agree that staffs from the Hong Kong Music Therapy Limited can contact me via phone call, WhatsApp or email.

Sign me up!