Music Therapy Registration Form
Please complete this form to register for music therapy services or adaptive lessons. All individual music therapy sessions begin with a music therapy assessment and you will be given an assessment report with recommended goals/objectives. Please note there is a one-time $25 assessment fee which will be added to the regular session price.
Contact Information
Client's Name *
Your answer
Date of Birth *
Your answer
Parent/Guardian Name *
Your answer
Address *
Your answer
City *
Your answer
Phone Number (xxx-xxx-xxxx) *
Your answer
Email Address *
Your answer
Musical Information
Has the client had previous music therapy services? If so, how long and where? *
Your answer
Has the client taken music lessons before? If so, what instrument? *
Your answer
List any of the client's preferred genres, instruments, or songs. *
Your answer
Diagnostic, Medical, and Safety Information
List any diagnosis and/or medical conditions: *
Your answer
Does the client have seizures? *
Is the client able to use the restroom independently? *
Are there any precautions that should be taken while working with the client? If so, please describe: *
Your answer
Does the client display aggression towards self or others? If so, describe: *
Your answer
Does the client engage in destruction of property, verbal outbursts, or disruptions? If so, please explain: *
Your answer
Does the client have any additional medical or safety concerns? If so, please explain: *
Your answer
Cognitive/Social/Motor/Communication Information
Is the client in school? *
Does the client have a full time para (or aide) assigned to them in school? *
Does the client have difficulty maintaining attention to task or following directions? If so, please explain: *
Your answer
Does the client receive any other therapies? Please list below: *
Your answer
Does the client have difficulties with fine or gross motor skills? Please list below: *
Your answer
Does the client get overstimulated by lights, sounds, or crowds? If so, please explain: *
Your answer
Please briefly describe any communication difficulties or augmentative/alternative communication used: *
Your answer
Please briefly describe any difficulties in social skills: *
Your answer
Please check your availability for sessions *
Required
Which days work best for you? *
Write any additional scheduling comments under "other"
Required
Please check which service(s) you are signing up for: *
Required
Choose your preferred method of payment, due each session: *
How did you hear about us? *
Required
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