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Supplemental Questionnaire

Last Name
First Name


***Please note that your answers on the supplemental questionnaire must correspond to the information provided on your application to receive credit.***


Do you possess a Bachelor’s or Master’s degree in music therapy from an accredited college or university?  

Yes No

If you do not possess a Bachelor's or Master's degree in music therapy, do you possess current certification as a Music Therapist from the American Music Therapy Association or the Certification Board for Music Therapists? If you possess this certification, please attach it to your application.

Yes No

Describe your experience performing music therapy work in the treatment of mentally ill, aged, physically ill or physically disabled patients or developmentally disabled clients.

Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.


Do you have four years of experience as a professional music therapist, under the supervision of a licensed Occupational Therapist, licensed Physical Therapist or certified Activity Therapist, which included the responsibility for clients’ assessments and the planning, implementation and evaluation of clients’ music therapy treatment in a mental health or developmental disability setting?  If so, please include the description of these duties in your application.

Yes No

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