Client Intake Form
Private Clients - Kids/Adolescents
Email address *
Phone Number
Your answer
Date *
MM
/
DD
/
YYYY
Name (Parent/Guardian) *
Your answer
General Information
Name (Client) *
Your answer
Age *
Your answer
Level of Education *
Your answer
Name of School *
Your answer
English as first language *
Medical Information
Diagnosis *
Your answer
Number of years *
Your answer
Involvement in other forms of therapy *
If yes, list therapies:
Your answer
Medications *
If yes, list medications and reasons:
Your answer
Behavioural Information
(E.g., Social skills, general attitudes/moods, etc) *
Your answer
Musical Information
Level of Musical Background (if applicable)
Your answer
Musical Preferences (e.g., genres, singers, songs) *
Your answer
Goals and Inquiries
What are you hoping to get out of these sessions? *
Your answer
Do you have any questions or concerns?
Your answer
Other Comments
Your answer
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